MEDICARE: MAINLINE CPL, LLC

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	PP413275L	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	:	1770638702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAINLINE CPL, LLC

Provider Business Mailing Address
First Line	:	619 MAIN ST
Second Line	:
City	:	PORTAGE
State	:	PA
Zip	:	15946-1539
Country	:	US
Telephone Number	:	814-736-4530
Fax Number	:	814-736-9522

Provider Business Practice Location Address
First Line	:	619 MAIN ST
Second Line	:
City	:	PORTAGE
State	:	PA
Zip	:	15946-1539
Country	:	US
Telephone Number	:	814-736-4530
Fax Number	:	814-736-9522

Authorized Official
Title or Position	:	CFO
Name	:	MR. STEVEN JOSEPH DECRISCIO
Credential	:
Telephone Number	:	814-408-6800

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	04/27/2022

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Directions to “MAINLINE CPL, LLC ” Practice Location

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