=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295824845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRMOUNT PHARMACY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 12/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 GREEN ST SUITE 2F
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19130-3207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-564-9300
-----------------------------------------------------
Fax | 215-567-1931
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 GREEN ST SUITE 2F
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19130-3207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-564-9300
-----------------------------------------------------
Fax | 215-567-1931
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER LLC PHARMACIST
-----------------------------------------------------
Name | GERARD VOLGRAF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-620-0019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | PP481626
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------