Provider Demographics
NPI:1477228906
Name:MK GLAM RX
Entity Type:Organization
Organization Name:MK GLAM RX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAEYONNI
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-609-2907
Mailing Address - Street 1:2290 W OREGON AVE # 1026
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4197
Mailing Address - Country:US
Mailing Address - Phone:267-399-0081
Mailing Address - Fax:
Practice Address - Street 1:2290 W OREGON AVE # 1026
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4197
Practice Address - Country:US
Practice Address - Phone:267-399-0081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MK GLAM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier