Provider Demographics
NPI:1093097206
Name:SHADELAND PHARMACY LLC
Entity Type:Organization
Organization Name:SHADELAND PHARMACY LLC
Other - Org Name:SHADELAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MAHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-207-1114
Mailing Address - Street 1:403 SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-1437
Mailing Address - Country:US
Mailing Address - Phone:610-622-1630
Mailing Address - Fax:610-622-1647
Practice Address - Street 1:403 SHADELAND AVE
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-1437
Practice Address - Country:US
Practice Address - Phone:610-622-1630
Practice Address - Fax:610-622-1647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4822323336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143594OtherPK