1629384979 NPI number — DELUXE DRUG STORES LLC

Table of content: (NPI 1629384979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629384979 NPI number — DELUXE DRUG STORES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELUXE DRUG STORES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DELUXE PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629384979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8749 FRANKFORD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19136-2126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-941-7689
Provider Business Mailing Address Fax Number:
215-941-7893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8749 FRANKFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19136-2126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-941-7689
Provider Business Practice Location Address Fax Number:
215-941-7893
Provider Enumeration Date:
08/24/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BALAMURI
Authorized Official First Name:
VENKATA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
215-941-7689

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PP482051 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1025140600001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3994337 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".