MEDICARE: TRACEMARK PHARMACY

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	3336C0003X	Community/Retail Pharmacy	PP481991	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215254305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRACEMARK PHARMACY

Provider Business Mailing Address
First Line	:	4839 N BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19141-2107
Country	:	US
Telephone Number	:	215-324-0800
Fax Number	:	215-324-0803

Provider Business Practice Location Address
First Line	:	4839 N BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19141-2107
Country	:	US
Telephone Number	:	215-324-0800
Fax Number	:	215-324-0803

Authorized Official
Title or Position	:	PHARMACY OWNER
Name	:	BEVIS E VANTERPOOL
Credential	:	PHARM.D.
Telephone Number	:	215-668-4494

Provider Enumeration Date	:	04/28/2010
Last Update Date	:	04/28/2010

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Directions to “TRACEMARK PHARMACY ” Practice Location

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