Provider Demographics
NPI:1760402606
Name:INDEPENDENT APOTHECARY INCORPORATED
Entity Type:Organization
Organization Name:INDEPENDENT APOTHECARY INCORPORATED
Other - Org Name:OLDE PHILLY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CIRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-739-0548
Mailing Address - Street 1:2923 E THOMPSON ST
Mailing Address - Street 2:1ST FLR FRONT
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4812
Mailing Address - Country:US
Mailing Address - Phone:215-739-0548
Mailing Address - Fax:215-739-1579
Practice Address - Street 1:2923 E THOMPSON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4812
Practice Address - Country:US
Practice Address - Phone:215-739-0548
Practice Address - Fax:215-739-1579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4815443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2087681OtherPK
PA015440460001Medicaid
2087681OtherPK