Provider Demographics
NPI:1255588687
Name:OAK LANE PHARMACY, INC
Entity type:Organization
Organization Name:OAK LANE PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:VIVIAN
Authorized Official - Last Name:RATHFON
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:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19126-2840
Mailing Address - Country:US
Mailing Address - Phone:215-924-9929
Mailing Address - Fax:
Practice Address - Street 1:6724 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19126-2840
Practice Address - Country:US
Practice Address - Phone:215-924-9929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4817923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021085070001Medicaid
PA1021085070001Medicaid