Provider Demographics
NPI:1679878185
Name:NANTICOKE PHARMACY LLC
Entity type:Organization
Organization Name:NANTICOKE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:BIMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-570-9948
Mailing Address - Street 1:1609A MIDDLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-3617
Mailing Address - Country:US
Mailing Address - Phone:302-536-7464
Mailing Address - Fax:302-536-7667
Practice Address - Street 1:1609A MIDDLEFORD RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3617
Practice Address - Country:US
Practice Address - Phone:302-536-7464
Practice Address - Fax:302-536-7667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
DEA3-00009273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1679878185Medicaid
2128634OtherPK