=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598023400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUR STAR PHARMACY II LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2012
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6542 LEBANON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19151-3328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-877-2400
-----------------------------------------------------
Fax | 215-877-2403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6542 LEBANON AVE APT A
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19151-3337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-877-2400
-----------------------------------------------------
Fax | 215-877-2403
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | DR. IYABODE LEAH ADEWALE
-----------------------------------------------------
Credential | PHARM.D
-----------------------------------------------------
Telephone | 215-877-2400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
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 | PP482266
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------