Provider Demographics
NPI:1689981060
Name:TAMAQUA PHARMACY LLC
Entity Type:Organization
Organization Name:TAMAQUA PHARMACY LLC
Other - Org Name:BRACEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAJUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-932-0521
Mailing Address - Street 1:626 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17921-1332
Mailing Address - Country:US
Mailing Address - Phone:570-875-1300
Mailing Address - Fax:570-875-2817
Practice Address - Street 1:626 CENTRE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:PA
Practice Address - Zip Code:17921-1332
Practice Address - Country:US
Practice Address - Phone:570-875-1300
Practice Address - Fax:570-875-2817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410237L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6495820001Medicare NSC