MEDICARE: EVANS CITY DRUG STORE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PP412566L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2087018	OTHER		PK

General Provider Information

NPI Number	:	1114096807
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVANS CITY DRUG STORE INC

Provider Business Mailing Address
First Line	:	201 E MAIN ST
Second Line	:
City	:	EVANS CITY
State	:	PA
Zip	:	16033-1219
Country	:	US
Telephone Number	:	724-538-4240
Fax Number	:	724-538-3826

Provider Business Practice Location Address
First Line	:	201 E MAIN ST
Second Line	:
City	:	EVANS CITY
State	:	PA
Zip	:	16033-1219
Country	:	US
Telephone Number	:	724-538-4240
Fax Number	:	724-538-3826

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JEFFREY MUSTOVIC
Credential	:	RPH
Telephone Number	:	724-538-4240

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	03/13/2017

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Directions to “EVANS CITY DRUG STORE INC ” Practice Location

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