Provider Demographics
NPI:1578835740
Name:EDDYSTONE COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:EDDYSTONE COMMUNITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IGDALIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:484-480-3341
Mailing Address - Street 1:1207B CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:EDDYSTONE
Mailing Address - State:PA
Mailing Address - Zip Code:19022-1332
Mailing Address - Country:US
Mailing Address - Phone:484-480-3341
Mailing Address - Fax:484-480-3344
Practice Address - Street 1:1207B CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:EDDYSTONE
Practice Address - State:PA
Practice Address - Zip Code:19022-1332
Practice Address - Country:US
Practice Address - Phone:484-480-3341
Practice Address - Fax:484-480-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
183500000X, 1835G0303X, 1835N1003X, 1835P0018X, 332B00000X, 3336C0004X, 3336S0011X
PAPP482215333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No1835G0303XPharmacy Service ProvidersPharmacistGeriatricGroup - Single Specialty
No1835N1003XPharmacy Service ProvidersPharmacistNutrition SupportGroup - Single Specialty
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No333600000XSuppliersPharmacyGroup - Single Specialty
No3336C0004XSuppliersPharmacyCompounding PharmacyGroup - Single Specialty
No3336S0011XSuppliersPharmacySpecialty Pharmacy