Provider Demographics
NPI:1689099202
Name:GOODWILL COMMUNITY PHARMACY LLC
Entity Type:Organization
Organization Name:GOODWILL COMMUNITY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:UCHE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-385-5458
Mailing Address - Street 1:5002 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-3642
Mailing Address - Country:US
Mailing Address - Phone:267-385-5554
Mailing Address - Fax:267-385-5485
Practice Address - Street 1:5002 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-3642
Practice Address - Country:US
Practice Address - Phone:267-385-5554
Practice Address - Fax:267-385-5485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4824213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029378990001Medicaid