Provider Demographics
NPI:1356419592
Name:G&A SOMERTON PHARMACY LLC
Entity type:Organization
Organization Name:G&A SOMERTON PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:INESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-969-9700
Mailing Address - Street 1:10806 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3302
Mailing Address - Country:US
Mailing Address - Phone:215-969-9700
Mailing Address - Fax:215-969-3905
Practice Address - Street 1:10806 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116
Practice Address - Country:US
Practice Address - Phone:215-969-9700
Practice Address - Fax:215-969-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4814233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2087052OtherPK
PA1011950430001Medicaid
PA5362700001Medicare NSC