Provider Demographics
NPI:1356789051
Name:MY PHILLY PHARMACY INC
Entity type:Organization
Organization Name:MY PHILLY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CIRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-560-8082
Mailing Address - Street 1:3140 WILLITS RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-1116
Mailing Address - Country:US
Mailing Address - Phone:267-686-2454
Mailing Address - Fax:267-773-7832
Practice Address - Street 1:3140 WILLITS RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-1116
Practice Address - Country:US
Practice Address - Phone:267-686-2454
Practice Address - Fax:267-773-7832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336S0011X
PAPP4823813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140615OtherPK
PA1028277800001Medicaid