Provider Demographics
NPI:1790012763
Name:INDEPENDENT PHARMACIES INCORPORATED
Entity Type:Organization
Organization Name:INDEPENDENT PHARMACIES INCORPORATED
Other - Org Name:CENTENNIAL PHARMACY SOUTHPHILLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DYMOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-468-2111
Mailing Address - Street 1:PO BOX 37544
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-7544
Mailing Address - Country:US
Mailing Address - Phone:215-468-2111
Mailing Address - Fax:215-468-0387
Practice Address - Street 1:2036-38 SOUTH 3RD STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148
Practice Address - Country:US
Practice Address - Phone:215-468-2111
Practice Address - Fax:215-468-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4819673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023943640001Medicaid
2122483OtherPK
PA1023943640001Medicaid