MEDICARE: COMMUNITY CARE RX LTC 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	333600000X	Pharmacy
2	3336L0003X	Long Term Care Pharmacy	PP482773	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2170894	OTHER		PK

General Provider Information

NPI Number	:	1437674173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE RX LTC LLC

Provider Business Mailing Address
First Line	:	7601 CASTOR AVE STE 201
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-4026
Country	:	US
Telephone Number	:	215-722-2500
Fax Number	:	215-722-7700

Provider Business Practice Location Address
First Line	:	7601 CASTOR AVE STE 201
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-4026
Country	:	US
Telephone Number	:	215-722-2500
Fax Number	:	215-722-7700

Authorized Official
Title or Position	:	OWNER
Name	:	YANA PEKAREVA
Credential	:
Telephone Number	:	267-255-2116

Provider Enumeration Date	:	08/03/2017
Last Update Date	:	02/13/2019

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