Provider Demographics
NPI:1003193228
Name:MAKEFIELD TOWN PHARMACY LLC
Entity Type:Organization
Organization Name:MAKEFIELD TOWN PHARMACY LLC
Other - Org Name:MAKEFIELD TOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ILHAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANZABI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-210-9795
Mailing Address - Street 1:1582 CLARK DR
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-4375
Mailing Address - Country:US
Mailing Address - Phone:267-210-9795
Mailing Address - Fax:215-295-5301
Practice Address - Street 1:99 MAKEFIELD RD
Practice Address - Street 2:
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-5943
Practice Address - Country:US
Practice Address - Phone:215-295-5300
Practice Address - Fax:215-295-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4822123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3996420OtherNCPDP PROVIDER IDENTIFICATION NUMBER