Provider Demographics
NPI:1942458906
Name:ATLANTIC PHARMACY
Entity Type:Organization
Organization Name:ATLANTIC PHARMACY
Other - Org Name:ATLANTIC PHARMACEUTICAL GROUP INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YU
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:215-355-6720
Mailing Address - Street 1:789 BUSTLETON PIKE
Mailing Address - Street 2:
Mailing Address - City:RICHBORO
Mailing Address - State:PA
Mailing Address - Zip Code:18954-1353
Mailing Address - Country:US
Mailing Address - Phone:215-355-6720
Mailing Address - Fax:215-310-5868
Practice Address - Street 1:789 BUSTLETON PIKE
Practice Address - Street 2:
Practice Address - City:RICHBORO
Practice Address - State:PA
Practice Address - Zip Code:18954-1353
Practice Address - Country:US
Practice Address - Phone:215-355-6720
Practice Address - Fax:215-310-5868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000007523332BP3500X
PAPP481968333600000X, 3336C0002X, 3336C0003X, 3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024157220002Medicaid
PA162474Medicare PIN
NJ179980Medicare PIN
PA180040Medicare PIN