Provider Demographics
NPI:1376727495
Name:SOURCE ONE PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:SOURCE ONE PHARMACY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANTINE
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:PIPPIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:610-696-3100
Mailing Address - Street 1:1140 MCDERMOTT DR STE 104
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4043
Mailing Address - Country:US
Mailing Address - Phone:610-696-3100
Mailing Address - Fax:610-696-7100
Practice Address - Street 1:1140 MCDERMOTT DR STE 104
Practice Address - Street 2:SUITE 104
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4043
Practice Address - Country:US
Practice Address - Phone:610-696-3100
Practice Address - Fax:610-696-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
NJ28RO000536003336C0004X
PAPP4818003336L0003X
NY0334143336S0011X
DEA9-00009773336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04172987Medicaid
DE1376727495Medicaid
2082394OtherPK
NJ0187470Medicaid
PA1021341960002Medicaid
MD535302500Medicaid
NY04172987Medicaid
DE1376727495Medicaid