Provider Demographics
NPI:1659829877
Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Entity Type:Organization
Organization Name:TRUSTEES OF THE UNIVERSITY OF PENNSYLVANIA
Other - Org Name:HOSPITAL OF THE UNIVERSITY OF PENNYLVANIA- VALLEY FORGE PHAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-796-2085
Mailing Address - Street 1:1001 CHESTERBROOK BLVD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BERWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19312-3805
Mailing Address - Country:US
Mailing Address - Phone:610-576-7545
Mailing Address - Fax:610-576-7560
Practice Address - Street 1:1001 CHESTERBROOK BLVD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BERWYN
Practice Address - State:PA
Practice Address - Zip Code:19312-3805
Practice Address - Country:US
Practice Address - Phone:610-576-7545
Practice Address - Fax:610-576-7560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-16
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP482675333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164003OtherPK
PA1001258770290Medicaid