Provider Demographics
NPI:1942751417
Name:OAKLANE PHARMACY 1 LLC
Entity Type:Organization
Organization Name:OAKLANE PHARMACY 1 LLC
Other - Org Name:OAKLANE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-924-9929
Mailing Address - Street 1:6724 OLD YORK RD.
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19126
Mailing Address - Country:US
Mailing Address - Phone:215-924-9929
Mailing Address - Fax:215-924-4847
Practice Address - Street 1:6724 OLD YORK RD.
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19126
Practice Address - Country:US
Practice Address - Phone:215-924-9929
Practice Address - Fax:215-924-4847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4817923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032381210001Medicaid
2165985OtherPK