MEDICARE: FAIRMOUNT PHARMACY SERVICES 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	3336S0011X	Specialty Pharmacy
2	333600000X	Pharmacy
3	3336L0003X	Long Term Care Pharmacy	PP481626	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
2	2081667	OTHER		PK

General Provider Information

NPI Number	:	1295824845
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRMOUNT PHARMACY SERVICES LLC

Provider Business Mailing Address
First Line	:	1900 GREEN ST
Second Line	:	SUITE 2F
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3207
Country	:	US
Telephone Number	:	215-564-9300
Fax Number	:	215-567-1931

Provider Business Practice Location Address
First Line	:	1900 GREEN ST
Second Line	:	SUITE 2F
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3207
Country	:	US
Telephone Number	:	215-564-9300
Fax Number	:	215-567-1931

Authorized Official
Title or Position	:	MEMBER LLC PHARMACIST
Name	:	GERARD VOLGRAF
Credential	:
Telephone Number	:	215-620-0019

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	12/13/2016

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Directions to “FAIRMOUNT PHARMACY SERVICES LLC ” Practice Location

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