Provider Demographics
NPI:1184993040
Name:MAINLINE PHARMACY EBENSBURG LLC
Entity type:Organization
Organization Name:MAINLINE PHARMACY EBENSBURG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DECRISCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-408-6800
Mailing Address - Street 1:1207 SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:CRESSON
Mailing Address - State:PA
Mailing Address - Zip Code:16630-0058
Mailing Address - Country:US
Mailing Address - Phone:814-408-6800
Mailing Address - Fax:814-886-2203
Practice Address - Street 1:3720 NEW GERMANY RD
Practice Address - Street 2:
Practice Address - City:EBENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15931-1862
Practice Address - Country:US
Practice Address - Phone:814-472-9390
Practice Address - Fax:814-472-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YA0400X, 174H00000X
3336C0003X
PAPP412694L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026914940003Medicaid
2133430OtherPK