MEDICARE: KRESGE LEBAR PHARMACY

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	183500000X	Pharmacist	PP411345L	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

General Provider Information

NPI Number	:	1750380564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRESGE LEBAR PHARMACY

Provider Business Mailing Address
First Line	:	425 MAIN ST
Second Line	:
City	:	STROUDSBURG
State	:	PA
Zip	:	18360-2462
Country	:	US
Telephone Number	:	570-421-0710
Fax Number	:	570-421-3405

Provider Business Practice Location Address
First Line	:	425 MAIN ST
Second Line	:
City	:	STROUDSBURG
State	:	PA
Zip	:	18360-2462
Country	:	US
Telephone Number	:	570-421-0710
Fax Number	:	570-421-3405

Authorized Official
Title or Position	:	STORE MANAGER
Name	:	MR. MATTINS PRICKISIE
Credential	:
Telephone Number	:	570-421-0710

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	08/22/2020

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Directions to “KRESGE LEBAR PHARMACY ” Practice Location

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