Provider Demographics
NPI:1720383920
Name:MT AIRY FAMILY PHARMACY
Entity Type:Organization
Organization Name:MT AIRY FAMILY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLALEKAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABIFARIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D,CPH
Authorized Official - Phone:215-242-3814
Mailing Address - Street 1:5715 GERMANTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-2136
Mailing Address - Country:US
Mailing Address - Phone:215-242-3814
Mailing Address - Fax:215-242-3818
Practice Address - Street 1:5715 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2136
Practice Address - Country:US
Practice Address - Phone:215-242-3814
Practice Address - Fax:215-242-3818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP482089183500000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty