Provider Demographics
NPI:1598760639
Name:GLENDALE PRESCRIPTION CENTER INC
Entity Type:Organization
Organization Name:GLENDALE PRESCRIPTION CENTER INC
Other - Org Name:GLENDALE PRESCRIPTION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMMARA
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:215-722-6200
Mailing Address - Street 1:7601 CASTOR AVE
Mailing Address - Street 2:STE 100 LOBBY
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-4026
Mailing Address - Country:US
Mailing Address - Phone:215-722-6200
Mailing Address - Fax:215-722-6211
Practice Address - Street 1:7601 CASTOR AVE
Practice Address - Street 2:STE 100 LOBBY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-4026
Practice Address - Country:US
Practice Address - Phone:215-722-6200
Practice Address - Fax:215-722-6211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336S0011X
PAPP4811173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018827750002Medicaid
2085890OtherPK
2085890OtherPK