Healthcare Provider Details

I. General information

NPI: 1770122764
Provider Name (Legal Business Name): FIRST STATE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 SILVERSIDE RD STE 104
WILMINGTON DE
19809-1768
US

IV. Provider business mailing address

223 WILMINGTON W CHESTER PIKE STE 214
CHADDS FORD PA
19317-9007
US

V. Phone/Fax

Practice location:
  • Phone: 844-365-7246
  • Fax:
Mailing address:
  • Phone: 302-766-5368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEFANIE PAULUS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 302-766-5368