MEDICARE: TIFFANY SURYA ATMADJA PHARMD

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	183500000X	Pharmacist	RP458601	PA

General Provider Information

NPI Number	:	1932050655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY SURYA ATMADJA PHARMD

Provider Business Mailing Address
First Line	:	7171 GILLESPIE ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19135-1203
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6150 N 5TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19120-1423
Country	:	US
Telephone Number	:	215-548-1110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2026
Last Update Date	:	02/07/2026

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Directions to “ TIFFANY SURYA ATMADJA PHARMD” Practice Location

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