MEDICARE: PERRY DRUG STORES INC AND SUBSIDIARIES

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		MI
2	3336C0003X	Community/Retail Pharmacy	1739	MI

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	2303941	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1972612257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERRY DRUG STORES INC AND SUBSIDIARIES

Provider Business Mailing Address
First Line	:	200 NEWBERRY COMMONS
Second Line	:
City	:	ETTERS
State	:	PA
Zip	:	17319-9363
Country	:	US
Telephone Number	:	717-761-2633
Fax Number	:	717-975-8659

Provider Business Practice Location Address
First Line	:	3273 WEST HURON STREET
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48328-3009
Country	:	US
Telephone Number	:	248-682-9400
Fax Number	:

Authorized Official
Title or Position	:	MANAGER ONLINE ADJUDICATION
Name	:	JENNIFER ZOREK
Credential	:
Telephone Number	:	717-975-5937

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	08/08/2008

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