MEDICARE: LANDIS SUPER MARKET 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PP481624	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	2088154	OTHER		PK

General Provider Information

NPI Number	:	1558469486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LANDIS SUPER MARKET INC

Provider Business Mailing Address
First Line	:	2700 SHELLY RD
Second Line	:
City	:	HARLEYSVILLE
State	:	PA
Zip	:	19438-1281
Country	:	US
Telephone Number	:	877-540-4748
Fax Number	:	801-716-4872

Provider Business Practice Location Address
First Line	:	2700 SHELLY RD
Second Line	:
City	:	HARLEYSVILLE
State	:	PA
Zip	:	19438-1281
Country	:	US
Telephone Number	:	215-513-3053
Fax Number	:	215-513-3052

Authorized Official
Title or Position	:	PIC
Name	:	DAVID GUTEKUNST
Credential	:	RPH
Telephone Number	:	215-513-3053

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/12/2016

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Directions to “LANDIS SUPER MARKET INC ” Practice Location

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