=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497039853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAND PLAZA PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2011
-----------------------------------------------------
Last Update Date | 10/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 965 BRISTOL PIKE
-----------------------------------------------------
City | BENSALEM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19020-8142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-447-8277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 965 BRISTOL PIKE
-----------------------------------------------------
City | BENSALEM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19020-8142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-447-8277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. DARRYL J BRODZINSKI
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 215-447-8277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------