Provider Demographics
NPI:1093092447
Name:PHILLY METRO PHARMACY LLC
Entity Type:Organization
Organization Name:PHILLY METRO PHARMACY LLC
Other - Org Name:PHILLY METRO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISRAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNLEYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-331-5626
Mailing Address - Street 1:25 E WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-2002
Mailing Address - Country:US
Mailing Address - Phone:267-331-5626
Mailing Address - Fax:267-331-5743
Practice Address - Street 1:25 E WALNUT LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2002
Practice Address - Country:US
Practice Address - Phone:267-331-5626
Practice Address - Fax:267-331-5743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
PAPP4821593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3996696OtherNCPDP PROVIDER IDENTIFICATION NUMBER