Provider Demographics
NPI:1487983128
Name:DANVILLE PHARMACY LLC
Entity type:Organization
Organization Name:DANVILLE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRANDIZIO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-284-4667
Mailing Address - Street 1:229 MILL ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-1964
Mailing Address - Country:US
Mailing Address - Phone:570-284-4669
Mailing Address - Fax:570-284-4670
Practice Address - Street 1:439 MILL ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-1063
Practice Address - Country:US
Practice Address - Phone:570-284-4667
Practice Address - Fax:570-284-4670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 3336C0003X
PAPP4819903336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024585050001Medicaid
3993652OtherNCPDP
3993652OtherNCPDP