Provider Demographics
NPI:1205837325
Name:A.A. DISPENSARY INC.
Entity Type:Organization
Organization Name:A.A. DISPENSARY INC.
Other - Org Name:BROOKS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HORGER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:215-338-3262
Mailing Address - Street 1:6552 TORRESDALE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19135-2822
Mailing Address - Country:US
Mailing Address - Phone:215-338-3262
Mailing Address - Fax:215-338-1185
Practice Address - Street 1:6552 TORRESDALE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19135-2822
Practice Address - Country:US
Practice Address - Phone:215-338-3262
Practice Address - Fax:215-338-1185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP410263L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0579830Medicaid
2079298OtherPK
PA0579830Medicaid