Provider Demographics
NPI:1811254493
Name:SOUTHMOORE PHARMACY LLC
Entity type:Organization
Organization Name:SOUTHMOORE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-287-6337
Mailing Address - Street 1:2453 PLAZA CT STE A
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:PA
Mailing Address - Zip Code:18014
Mailing Address - Country:US
Mailing Address - Phone:484-287-6337
Mailing Address - Fax:484-287-6340
Practice Address - Street 1:2453 PLAZA CT STE A
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:PA
Practice Address - Zip Code:18014-8762
Practice Address - Country:US
Practice Address - Phone:484-287-6337
Practice Address - Fax:484-287-6340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-19
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4821963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3997181OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PA6953550001Medicare NSC