Healthcare Provider Details

I. General information

NPI: 1790157618
Provider Name (Legal Business Name): PREMIER PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MONUMENT RD STE 601A
BALA CYNWYD PA
19004-1701
US

IV. Provider business mailing address

150 MONUMENT RD SUITE 601A
BALA CYNWYD PA
19004-1702
US

V. Phone/Fax

Practice location:
  • Phone: 484-270-6501
  • Fax:
Mailing address:
  • Phone: 484-270-6501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPP482598
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MIROSLAV KESIC
Title or Position: PRESIDENT
Credential:
Phone: 484-270-6501