Provider Demographics
NPI:1922265271
Name:PHILADELPHIA PROFESSIONAL COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:PHILADELPHIA PROFESSIONAL COMPOUNDING PHARMACY LLC
Other - Org Name:PPC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:BS IN PHARMACY
Authorized Official - Phone:215-605-9211
Mailing Address - Street 1:23 S YORK RD FRNT
Mailing Address - Street 2:
Mailing Address - City:HATBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19040-3231
Mailing Address - Country:US
Mailing Address - Phone:215-672-8552
Mailing Address - Fax:215-672-8555
Practice Address - Street 1:23 S YORK RD FRNT
Practice Address - Street 2:
Practice Address - City:HATBORO
Practice Address - State:PA
Practice Address - Zip Code:19040-3231
Practice Address - Country:US
Practice Address - Phone:215-672-8552
Practice Address - Fax:215-672-8555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4817993336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3990391OtherNCPDP PROVIDER IDENTIFICATION NUMBER