Provider Demographics
NPI:1891330031
Name:PENNCARE PHARMACY
Entity Type:Organization
Organization Name:PENNCARE PHARMACY
Other - Org Name:PENNCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:K
Authorized Official - Last Name:JIBI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:615-335-2760
Mailing Address - Street 1:4427 MASTER AVE
Mailing Address - Street 2:
Mailing Address - City:TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-6926
Mailing Address - Country:US
Mailing Address - Phone:215-444-7525
Mailing Address - Fax:
Practice Address - Street 1:416 OAK LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19126-3136
Practice Address - Country:US
Practice Address - Phone:215-444-7525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-12
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPP482935OtherSTATE LICENSE