Provider Demographics
NPI:1295824845
Name:FAIRMOUNT PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:FAIRMOUNT PHARMACY SERVICES LLC
Other - Org Name:FAIRMOUNT PHARMACY SERVICES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER LLC PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLGRAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-620-0019
Mailing Address - Street 1:1900 GREEN ST
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3207
Mailing Address - Country:US
Mailing Address - Phone:215-564-9300
Mailing Address - Fax:215-567-1931
Practice Address - Street 1:1900 GREEN ST
Practice Address - Street 2:SUITE 2F
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-3207
Practice Address - Country:US
Practice Address - Phone:215-564-9300
Practice Address - Fax:215-567-1931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
PAPP4816263336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017523250001Medicaid
2081667OtherPK
PA1017523250001Medicaid