Healthcare Provider Details

I. General information

NPI: 1649443938
Provider Name (Legal Business Name): TRADITIONAL APOTHECARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 N SPRINGFIELD RD
CLIFTON HEIGHTS PA
19018-1304
US

IV. Provider business mailing address

PO BOX 232
CLIFTON HEIGHTS PA
19018-0232
US

V. Phone/Fax

Practice location:
  • Phone: 484-461-4555
  • Fax: 484-461-4556
Mailing address:
  • Phone: 484-461-4555
  • Fax: 484-461-4556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP481812
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: VINCENT CANZANESE
Title or Position: PRESIDENT
Credential:
Phone: 484-461-4555