=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659665271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOODHEART PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2011
-----------------------------------------------------
Last Update Date | 08/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4835 WOODLAND AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19143-4433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-724-3300
-----------------------------------------------------
Fax | 215-724-3301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4835 WOODLAND AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19143-4433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-724-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST INCHARGE
-----------------------------------------------------
Name | OBIOMA AGUOCHA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-724-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP482140
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------