Provider Demographics
NPI:1922238781
Name:EASTERN REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:EASTERN REGIONAL MEDICAL CENTER INC
Other - Org Name:PHARMACY & NUTRITION SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RETAIL PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:215-537-7626
Mailing Address - Street 1:1331 E WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3808
Mailing Address - Country:US
Mailing Address - Phone:215-537-7626
Mailing Address - Fax:215-537-7987
Practice Address - Street 1:1331 E WYOMING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3808
Practice Address - Country:US
Practice Address - Phone:215-537-7626
Practice Address - Fax:215-537-7987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
PAPP4819123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121072OtherPK