Healthcare Provider Details

I. General information

NPI: 1295040509
Provider Name (Legal Business Name): MIRIAM DATIKASHVILI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 RED LION RD
PHILADELPHIA PA
19114-1129
US

IV. Provider business mailing address

476 DEPUE PL
PHILADELPHIA PA
19116-2006
US

V. Phone/Fax

Practice location:
  • Phone: 215-637-1200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP441275
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: