Healthcare Provider Details

I. General information

NPI: 1093097206
Provider Name (Legal Business Name): SHADELAND PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 SHADELAND AVE
DREXEL HILL PA
19026-1437
US

IV. Provider business mailing address

403 SHADELAND AVE
DREXEL HILL PA
19026-1437
US

V. Phone/Fax

Practice location:
  • Phone: 610-622-1630
  • Fax: 610-622-1647
Mailing address:
  • Phone: 610-622-1630
  • Fax: 610-622-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP482232
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MAHEN PATEL
Title or Position: MEMBER
Credential:
Phone: 267-207-1114