Healthcare Provider Details

I. General information

NPI: 1497017461
Provider Name (Legal Business Name): INNOVATIVE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 08/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 FORD RD STE B
BRISTOL PA
19007-6743
US

IV. Provider business mailing address

2014 FORD ROAD UNIT B
BRISTOL PA
19007
US

V. Phone/Fax

Practice location:
  • Phone: 267-878-0492
  • Fax: 267-878-0534
Mailing address:
  • Phone: 267-878-0492
  • Fax: 267-878-0534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPP482279
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3997701
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: EVAN LANDA
Title or Position: MANAGING MEMBER
Credential:
Phone: 908-216-6680