=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083187520
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST GOSHEN PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2019
-----------------------------------------------------
Last Update Date | 10/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 729 GROVE AVE UNIT 5
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18966-6008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-344-0450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4222 PAYSPHERE CIRCLE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60674-0042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-879-6137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CFO
-----------------------------------------------------
Name | MICHAEL SHAPIRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-879-6137
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------