MEDICARE: BOSCOVS DEPARTMENT STORE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1063346823
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOSCOVS DEPARTMENT STORE LLC

Provider Business Mailing Address
First Line	:	4500 PERKIOMEN AVE
Second Line	:
City	:	READING
State	:	PA
Zip	:	19606-3946
Country	:	US
Telephone Number	:	610-779-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1067 W BALTIMORE PIKE
Second Line	:
City	:	MEDIA
State	:	PA
Zip	:	19063-5141
Country	:	US
Telephone Number	:	610-566-5255
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPTICAL SERVICES
Name	:	MICHAEL DERENZO
Credential	:
Telephone Number	:	856-759-9905

Provider Enumeration Date	:	06/09/2026
Last Update Date	:	06/09/2026

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Directions to “BOSCOVS DEPARTMENT STORE LLC ” Practice Location

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