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General NPI Number Information
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NPI Number | 1609120930
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Entity Type | Organization
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Legal Business Name | PHARMACY AT RIDGE & MIDVALE
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Dates
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Enumeration Date | 11/08/2012
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Last Update Date | 11/08/2012
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Provider Practice Location Address
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Address Line | 4219 RIDGE AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19129-1745
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Country | US
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Telephone | 267-385-6024
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Fax | 267-385-6238
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Provider Business Mailing Address
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Address Line | 4219 RIDGE AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19129-1745
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Country | US
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Telephone | 267-385-6024
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Fax | 267-385-6238
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Authorized Official
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Title or Position | OWNER/PRESIDENT/CEO
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Name | KOFI DEI GBOMITA
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Credential | PHARMD
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Telephone | 267-664-2388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PP482271
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License Number State | PA
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