Provider Demographics
NPI:1033102967
Name:FASTVAX LLC
Entity Type:Organization
Organization Name:FASTVAX LLC
Other - Org Name:FASTVAX PHARMACY AND VACCINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-996-1400
Mailing Address - Street 1:829 SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5752
Mailing Address - Country:US
Mailing Address - Phone:215-923-7070
Mailing Address - Fax:215-923-0489
Practice Address - Street 1:829 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5752
Practice Address - Country:US
Practice Address - Phone:215-923-7070
Practice Address - Fax:215-923-0489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP413108L333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3921613OtherNCPDP
3921613OtherNCPDP PROVIDER IDENTIFICATION NUMBER