MEDICARE: CLAYSVILLE PHARMACY, 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	332B00000X	Durable Medical Equipment & Medical Supplies	PP481704	PA
3	163WD0400X	Diabetes Educator Registered Nurse
4	3336C0003X	Community/Retail Pharmacy	PP481704	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PP481704	OTHER	PA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1871710418
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLAYSVILLE PHARMACY, LLC

Provider Business Mailing Address
First Line	:	575 HENDERSON AVE
Second Line	:
City	:	WASHINGTON
State	:	PA
Zip	:	15301-1901
Country	:	US
Telephone Number	:	724-225-1592
Fax Number	:	724-225-1651

Provider Business Practice Location Address
First Line	:	575 HENDERSON AVE
Second Line	:
City	:	WASHINGTON
State	:	PA
Zip	:	15301-1901
Country	:	US
Telephone Number	:	724-225-1592
Fax Number	:	724-225-1651

Authorized Official
Title or Position	:	VP
Name	:	MR. ERICH JOHN CUSHEY
Credential	:	RPH
Telephone Number	:	724-225-1592

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	03/24/2026

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Directions to “CLAYSVILLE PHARMACY, LLC ” Practice Location

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