Provider Demographics
NPI:1356371587
Name:MEDICAL TOWER PHARMACY INC
Entity type:Organization
Organization Name:MEDICAL TOWER PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:HELLER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:215-545-3525
Mailing Address - Street 1:255 S 17TH ST
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6231
Mailing Address - Country:US
Mailing Address - Phone:215-545-3525
Mailing Address - Fax:215-732-7013
Practice Address - Street 1:255 S 17TH ST
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19103-6231
Practice Address - Country:US
Practice Address - Phone:215-545-3525
Practice Address - Fax:215-732-7013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410793L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010724800001Medicaid
PAPP410793LOtherSTATE LICENSE
BM0782246OtherDEA