Organization
GRANE SUPPLY, INC.
Active
Other names
Elwyn Rx at Fair Acres
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ROBERT CHARLES FUNDERLICH (CHIEF FINANCIAL OFFICER)
(412) 449-0690
Entity
Organization
Contact information
Practice address
340 N MIDDLETOWN RD, LIMA, PA 19063
(610) 891-5783
(610) 891-5860
Mailing address
105 GAMMA DRIVE, SUITE 100, PITTSBURGH, PA 15238
(412) 449-0680
(129) 685-8004
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336L0003X
Long Term Care Pharmacy
Primary
PP482618
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1008270470004
—
PA
01
—
PP482618
BOARD OF PHARMACY
PA
Enumeration date
11/30/2015
Last updated
07/27/2021
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