Provider Demographics
NPI:1871710418
Name:CLAYSVILLE PHARMACY, LLC
Entity type:Organization
Organization Name:CLAYSVILLE PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:ERICH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CUSHEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:724-225-1592
Mailing Address - Street 1:575 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-1901
Mailing Address - Country:US
Mailing Address - Phone:724-225-1592
Mailing Address - Fax:724-225-1651
Practice Address - Street 1:869 HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-1361
Practice Address - Country:US
Practice Address - Phone:724-225-1592
Practice Address - Fax:724-225-1651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WD0400X, 332B00000X
PAPP481704332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPP481704OtherSTATE LICENSE NUMBER
PA5739680002Medicare NSC