1609120930 NPI number — PHARMACY AT RIDGE & MIDVALE

Table of content: (NPI 1609120930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609120930 NPI number — PHARMACY AT RIDGE & MIDVALE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMACY AT RIDGE & MIDVALE
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:
1609120930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4219 RIDGE 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:
19129-1745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-385-6024
Provider Business Mailing Address Fax Number:
267-385-6238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4219 RIDGE 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:
19129-1745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-385-6024
Provider Business Practice Location Address Fax Number:
267-385-6238
Provider Enumeration Date:
11/08/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GBOMITA
Authorized Official First Name:
KOFI
Authorized Official Middle Name:
DEI
Authorized Official Title or Position:
OWNER/PRESIDENT/CEO
Authorized Official Telephone Number:
267-664-2388

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PP482271 , 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)