Provider Demographics
NPI:1609120930
Name:PHARMACY AT RIDGE & MIDVALE
Entity Type:Organization
Organization Name:PHARMACY AT RIDGE & MIDVALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KOFI
Authorized Official - Middle Name:DEI
Authorized Official - Last Name:GBOMITA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:267-664-2388
Mailing Address - Street 1:4219 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1745
Mailing Address - Country:US
Mailing Address - Phone:267-385-6024
Mailing Address - Fax:267-385-6238
Practice Address - Street 1:4219 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1745
Practice Address - Country:US
Practice Address - Phone:267-385-6024
Practice Address - Fax:267-385-6238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4822713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy