Provider Demographics
NPI:1114999042
Name:MAYFAIR DRUG STORE INC
Entity Type:Organization
Organization Name:MAYFAIR DRUG STORE INC
Other - Org Name:MAYFAIR DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PRISTAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-338-2626
Mailing Address - Street 1:7522 FRANKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-3533
Mailing Address - Country:US
Mailing Address - Phone:215-338-2626
Mailing Address - Fax:215-338-5209
Practice Address - Street 1:7522 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-3533
Practice Address - Country:US
Practice Address - Phone:215-338-2626
Practice Address - Fax:215-338-5209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-04
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4815043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014416570001Medicaid
3985085OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5550030001Medicare NSC