Healthcare Provider Details

I. General information

NPI: 1184089344
Provider Name (Legal Business Name): CHARRELL S PORTER PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 N BROAD ST
PHILADELPHIA PA
19140-5101
US

IV. Provider business mailing address

3307 N BROAD ST
PHILADELPHIA PA
19140-5101
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-5098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberRP449876
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: