=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003193228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAKEFIELD TOWN PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2011
-----------------------------------------------------
Last Update Date | 01/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 99 MAKEFIELD RD
-----------------------------------------------------
City | YARDLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19067-5943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-295-5300
-----------------------------------------------------
Fax | 215-295-5301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1582 CLARK DR
-----------------------------------------------------
City | YARDLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19067-4375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-210-9795
-----------------------------------------------------
Fax | 215-295-5301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY PRESIDENT
-----------------------------------------------------
Name | ILHAMA ANZABI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 267-210-9795
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP482212
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------