Provider Demographics
NPI:1649601998
Name:BOOTHWYN APOTHECARY, LLC
Entity Type:Organization
Organization Name:BOOTHWYN APOTHECARY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO & MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MICOLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:610-485-1130
Mailing Address - Street 1:2341 CHICHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER CHICHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19061-3737
Mailing Address - Country:US
Mailing Address - Phone:610-485-1130
Mailing Address - Fax:610-485-9223
Practice Address - Street 1:2341 CHICHESTER AVE
Practice Address - Street 2:
Practice Address - City:UPPER CHICHESTER
Practice Address - State:PA
Practice Address - Zip Code:19061-3737
Practice Address - Country:US
Practice Address - Phone:610-485-1130
Practice Address - Fax:610-485-9223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4822583336C0003X, 3336H0001X, 3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5661670001Medicare NSC