=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154778983
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HILLRISE PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2016
-----------------------------------------------------
Last Update Date | 07/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4240 N BROAD ST UNIT B
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19140-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-403-7300
-----------------------------------------------------
Fax | 267-335-3937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4240 N BROAD ST UNIT B
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19140-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-403-7300
-----------------------------------------------------
Fax | 267-335-3937
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/OWNER
-----------------------------------------------------
Name | OMOTAYO BADEJOKO
-----------------------------------------------------
Credential | B PHARM
-----------------------------------------------------
Telephone | 484-326-1877
-----------------------------------------------------
=====================================================
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 | PP482646
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------