=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225854193
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMSCENE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2024
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6519 FRANKFORD AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19135-2538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-624-4224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 486 AURANIA ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-4011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-269-5129
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LANCE MARTIN WETZEL JR.
-----------------------------------------------------
Credential | PHARM.D
-----------------------------------------------------
Telephone | 267-269-5129
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------