MEDICARE: KINGDOM PHARMACY 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	PP482480	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	2145885	OTHER		PK

General Provider Information

NPI Number	:	1972915189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGDOM PHARMACY LLC

Provider Business Mailing Address
First Line	:	9014 W CHESTER PIKE
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-2606
Country	:	US
Telephone Number	:	484-455-7915
Fax Number	:	484-455-7923

Provider Business Practice Location Address
First Line	:	9014 W CHESTER PIKE
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-2606
Country	:	US
Telephone Number	:	484-455-7915
Fax Number	:	484-455-7923

Authorized Official
Title or Position	:	MANAGER
Name	:	MARTINE KOUAHOU
Credential	:
Telephone Number	:	484-455-7915

Provider Enumeration Date	:	05/21/2014
Last Update Date	:	11/29/2016

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Directions to “KINGDOM PHARMACY LLC ” Practice Location

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