=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093092447
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILLY METRO PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2011
-----------------------------------------------------
Last Update Date | 05/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 E WALNUT LN
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19144-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-331-5626
-----------------------------------------------------
Fax | 267-331-5743
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 E WALNUT LN
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19144-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-331-5626
-----------------------------------------------------
Fax | 267-331-5743
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ISRAEL OGUNLEYE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 267-331-5626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP482159
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------