MEDICARE: OLIVE TREE HEALTHCARE 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	3336C0003X	Community/Retail Pharmacy

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	:	1780269175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE TREE HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	253 S 60TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139-3844
Country	:	US
Telephone Number	:	610-257-3105
Fax Number	:	610-257-3104

Provider Business Practice Location Address
First Line	:	253 S 60TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139-3844
Country	:	US
Telephone Number	:	610-257-3105
Fax Number	:	610-257-3104

Authorized Official
Title or Position	:	PHARMACIST MANAGER
Name	:	MR. ADIGUN OLATUBOSUN ITABIYI
Credential	:	RPH
Telephone Number	:	610-257-3105

Provider Enumeration Date	:	03/16/2021
Last Update Date	:	09/24/2024

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Directions to “OLIVE TREE HEALTHCARE LLC ” Practice Location

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