Provider Demographics
NPI:1144289299
Name:VALENTINE PHARMACY
Entity type:Organization
Organization Name:VALENTINE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGELLO MOLLICA
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:724-564-1700
Mailing Address - Street 1:92 N MORGANTOWN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRCHANCE
Mailing Address - State:PA
Mailing Address - Zip Code:15436-1038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:92 N MORGANTOWN ST
Practice Address - Street 2:
Practice Address - City:FAIRCHANCE
Practice Address - State:PA
Practice Address - Zip Code:15436-1038
Practice Address - Country:US
Practice Address - Phone:724-564-1700
Practice Address - Fax:724-564-1704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-18
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4812223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3981645OtherOTHER ID NUMBER
PA19411230001Medicaid
5001620001Medicare NSC