Healthcare Provider Details

I. General information

NPI: 1922265271
Provider Name (Legal Business Name): PHILADELPHIA PROFESSIONAL COMPOUNDING PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 S YORK RD FRNT
HATBORO PA
19040-3231
US

IV. Provider business mailing address

23 S YORK RD FRNT
HATBORO PA
19040-3231
US

V. Phone/Fax

Practice location:
  • Phone: 215-672-8552
  • Fax: 215-672-8555
Mailing address:
  • Phone: 215-672-8552
  • Fax: 215-672-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP481799
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL CAVANAUGH
Title or Position: PARTNER
Credential: BS IN PHARMACY
Phone: 215-605-9211