Healthcare Provider Details

I. General information

NPI: 1306261169
Provider Name (Legal Business Name): 52ND STREET PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 N 52ND ST
PHILADELPHIA PA
19131-4315
US

IV. Provider business mailing address

1226 N 52ND ST
PHILADELPHIA PA
19131-4315
US

V. Phone/Fax

Practice location:
  • Phone: 267-713-7066
  • Fax: 215-921-2708
Mailing address:
  • Phone: 610-704-8594
  • Fax: 215-921-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPP482438
License Number StatePA

VIII. Authorized Official

Name: OLALEKAN ABIFARIN
Title or Position: OWNER
Credential:
Phone: 267-713-7066