Healthcare Provider Details

I. General information

NPI: 1578835740
Provider Name (Legal Business Name): EDDYSTONE COMMUNITY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207B CHESTER PIKE
EDDYSTONE PA
19022-1332
US

IV. Provider business mailing address

1207B CHESTER PIKE
EDDYSTONE PA
19022-1332
US

V. Phone/Fax

Practice location:
  • Phone: 484-480-3341
  • Fax: 484-480-3344
Mailing address:
  • Phone: 484-480-3341
  • Fax: 484-480-3344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPP482215
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
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP482215
License Number StatePA

VIII. Authorized Official

Name: MR. IGDALIAH JACKSON
Title or Position: PHARMACIST/OWNER
Credential: PHARMD
Phone: 484-480-3341