MEDICARE: SUBURBAN BUSTLETON PHARMACY INC.

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	PP412433L	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	:	1962560565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUBURBAN BUSTLETON PHARMACY INC.

Provider Business Mailing Address
First Line	:	10875 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3301
Country	:	US
Telephone Number	:	215-673-0994
Fax Number	:	215-969-6176

Provider Business Practice Location Address
First Line	:	10875 BUSTLETON AVENUE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3301
Country	:	US
Telephone Number	:	215-673-0994
Fax Number	:	215-969-6176

Authorized Official
Title or Position	:	OWNER
Name	:	MS. JANE DZIERZA
Credential	:
Telephone Number	:	215-673-0994

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	04/27/2022

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