Provider Demographics
NPI:1619056389
Name:TIRELLI INC
Entity Type:Organization
Organization Name:TIRELLI INC
Other - Org Name:BROAD STREET APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:TIROTTO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:215-551-9485
Mailing Address - Street 1:2426 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4418
Mailing Address - Country:US
Mailing Address - Phone:215-551-9485
Mailing Address - Fax:215-468-7189
Practice Address - Street 1:2426 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4418
Practice Address - Country:US
Practice Address - Phone:215-551-9485
Practice Address - Fax:215-468-7189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP414268L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2079620OtherPK
PA1182580Medicaid
PA1182580Medicaid