Organization
PENN TRAFFIC CO
Active
Organization
PENN TRAFFIC CO
Active
Other names
BILO FOODS AND PHARMACY 9003
Organization subpart
No
Provider details
NPI number
Authorized official
DANIEL J MAHONEY ESQ. (SVP/GENERAL COUNSEL)
(315) 461-2347
Entity
Organization
Contact information
Practice address
100 N MAIN ST, DU BOIS, PA 15801-1888
(814) 371-9000
(814) 375-9704
Mailing address
1200 STATE FAIR BLVD, SYRACUSE, NY 13209-1070
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
PP412682L
PA
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01215180
—
PA
01
—
1007783900001
PA PROMISE- MEDICAID
—
01
—
3961035
NCPDP
—
Enumeration date
07/21/2006
Last updated
02/10/2010
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