Provider Demographics
NPI: | 1477864924 |
---|---|
Name: | E-GLAM INC |
Entity Type: | Organization |
Organization Name: | E-GLAM INC |
Other - Org Name: | E-GLAM PHARMACY II |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | INYANG |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | INYANG |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PHARMD |
Authorized Official - Phone: | 215-763-1405 |
Mailing Address - Street 1: | 1412 WEST SUSQUEHANNA AVENUE |
Mailing Address - Street 2: | |
Mailing Address - City: | PHILADELPHIA |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 19122 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 215-763-1405 |
Mailing Address - Fax: | 215-232-1878 |
Practice Address - Street 1: | 1412 W SUSQUEHANNA AVE |
Practice Address - Street 2: | |
Practice Address - City: | PHILADELPHIA |
Practice Address - State: | PA |
Practice Address - Zip Code: | 19121-1684 |
Practice Address - Country: | US |
Practice Address - Phone: | 215-763-1405 |
Practice Address - Fax: | 215-232-1878 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | E-GLAM INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2010-06-30 |
Last Update Date: | 2010-06-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | PP482026 | 333600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 333600000X | Suppliers | Pharmacy |