Healthcare Provider Details

I. General information

NPI: 1639034374
Provider Name (Legal Business Name): JEANNIE LIU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 W OREGON AVE
PHILADELPHIA PA
19145-4122
US

IV. Provider business mailing address

1224 WOLF ST
PHILADELPHIA PA
19148-2910
US

V. Phone/Fax

Practice location:
  • Phone: 215-468-2481
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP460084
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: