Provider Demographics
NPI:1336488998
Name:JA COBEX, LLC
Entity Type:Organization
Organization Name:JA COBEX, LLC
Other - Org Name:PHILLY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ONIATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-969-5180
Mailing Address - Street 1:1900 GRANT AVE STE F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4370
Mailing Address - Country:US
Mailing Address - Phone:215-969-5180
Mailing Address - Fax:866-379-3198
Practice Address - Street 1:1900 GRANT AVE STE F
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4370
Practice Address - Country:US
Practice Address - Phone:215-969-5180
Practice Address - Fax:866-379-3198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4821443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028047850002Medicaid
2138971OtherPK