Healthcare Provider Details

I. General information

NPI: 1164779617
Provider Name (Legal Business Name): MADAME RX , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 HENDERSON BLVD
FOLCROFT PA
19032-1805
US

IV. Provider business mailing address

950 HENDERSON BLVD
FOLCROFT PA
19032-1805
US

V. Phone/Fax

Practice location:
  • Phone: 855-790-0100
  • Fax: 267-861-0862
Mailing address:
  • Phone: 855-790-0100
  • Fax: 267-861-0862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberRP038763L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberRP038763L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberRP038763L
License Number StatePA

VIII. Authorized Official

Name: AMANY FARID MANSOUR-AWAD
Title or Position: PHARMACIST
Credential: RPH
Phone: 855-790-0100