Provider Demographics
NPI:1295807329
Name:COSTA DRUGS INC
Entity type:Organization
Organization Name:COSTA DRUGS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORP SEC
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHELLAND
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-961-1168
Mailing Address - Street 1:609 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2772
Mailing Address - Country:US
Mailing Address - Phone:570-961-1168
Mailing Address - Fax:570-207-4633
Practice Address - Street 1:609 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-2772
Practice Address - Country:US
Practice Address - Phone:570-961-1168
Practice Address - Fax:570-207-4633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
PAPP410487L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007612680003Medicaid
2078775OtherPK
0525620001Medicare NSC