=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013775659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONG TERM CARE AT HOME ASSOCIATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2024
-----------------------------------------------------
Last Update Date | 03/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 N DELAWARE AVE FLOOR 2
-----------------------------------------------------
City | PHILADEPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19125-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-725-6011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020 N DELAWARE AVE FLOOR 2
-----------------------------------------------------
City | PHILADEPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19125-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-725-6011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP CLIENT SUCCESS
-----------------------------------------------------
Name | KELLY KNIGHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-725-6011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------