Provider Demographics
NPI:1053646372
Name:PHILLY PHARMACY LLC
Entity Type:Organization
Organization Name:PHILLY PHARMACY LLC
Other - Org Name:PHILLY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-625-6668
Mailing Address - Street 1:210 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-2805
Mailing Address - Country:US
Mailing Address - Phone:215-625-6668
Mailing Address - Fax:888-364-8994
Practice Address - Street 1:210 MARKET ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-2805
Practice Address - Country:US
Practice Address - Phone:215-625-6668
Practice Address - Fax:888-364-8994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4819453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023827480001Medicaid
3992698OtherNCPDP PROVIDER IDENTIFICATION NUMBER