Healthcare Provider Details

I. General information

NPI: 1033115928
Provider Name (Legal Business Name): GARY'S RX SHOPPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 E STREET RD
FEASTERVILLE TREVOSE PA
19053-6047
US

IV. Provider business mailing address

33 E STREET RD
FEASTERVILLE TREVOSE PA
19053-6047
US

V. Phone/Fax

Practice location:
  • Phone: 215-364-8770
  • Fax: 215-364-1792
Mailing address:
  • Phone: 215-364-8770
  • Fax: 215-364-1792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPP413261L
License Number StatePA

VIII. Authorized Official

Name: IRA GARY FRIED
Title or Position: PRESIDENT-RPH
Credential: R.PH.
Phone: 215-364-8770