Healthcare Provider Details

I. General information

NPI: 1417038191
Provider Name (Legal Business Name): PHILADELPHIA DEPARTMENT OF PUBLIC HEALTH CENTER PHARMACY #10
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 COTTMAN AVENUE
PHILADELPHIA PA
19149
US

IV. Provider business mailing address

500 S. BROAD STREET PHARMACY/BASEMENT
PHILADELPHIA PA
19146
US

V. Phone/Fax

Practice location:
  • Phone: 215-685-0616
  • Fax:
Mailing address:
  • Phone: 215-685-6864
  • Fax: 215-790-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberHP418337L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY T. PENDER
Title or Position: DIRECTOR OF PHARMACEUTICAL SERVICES
Credential: RPH
Phone: 215-685-6864