1376727495 NPI number — SOURCE ONE PHARMACY SERVICES LLC

Table of content: (NPI 1376727495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376727495 NPI number — SOURCE ONE PHARMACY SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOURCE ONE PHARMACY SERVICES 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:
Provider Other Organization Name Type Code:
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:
1376727495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1140 MCDERMOTT DR STE 104
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
WEST CHESTER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19380-4043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-696-3100
Provider Business Mailing Address Fax Number:
610-696-7100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 MCDERMOTT DR STE 104
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
WEST CHESTER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19380-4043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-696-3100
Provider Business Practice Location Address Fax Number:
610-696-7100
Provider Enumeration Date:
12/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PIPPIS
Authorized Official First Name:
CONSTANTINE
Authorized Official Middle Name:
NICHOLAS
Authorized Official Title or Position:
OWNER/PHARMACIST
Authorized Official Telephone Number:
610-696-3100

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04172987 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376727495 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2082394 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0187470 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1021341960002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 535302500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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