Provider Demographics
NPI:1164518866
Name:PHILADELPHIA DEPARTMENT OF PUBLIC HEALTH CENTER PHARMACY #4
Entity Type:Organization
Organization Name:PHILADELPHIA DEPARTMENT OF PUBLIC HEALTH CENTER PHARMACY #4
Other - Org Name:PHARMACY HEALTH CENTER #4
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACEUTICAL SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:PENDER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:215-685-6864
Mailing Address - Street 1:500 S. BROAD STREET
Mailing Address - Street 2:PHARMACY/BASEMENT
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146
Mailing Address - Country:US
Mailing Address - Phone:215-685-6864
Mailing Address - Fax:215-790-1651
Practice Address - Street 1:4400 HAVERFORD AVENUE
Practice Address - Street 2:PHARMACY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-685-7926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAHP418324L261QP0905X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000076950039Medicaid