=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801067129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OAK LANE PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2008
-----------------------------------------------------
Last Update Date | 02/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6724 OLD YORK RD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19126-2840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-924-9929
-----------------------------------------------------
Fax | 215-924-4847
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6724 OLD YORK RD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19126-2840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-924-9929
-----------------------------------------------------
Fax | 215-924-4847
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JUANITA RATHFON
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 215-924-9929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP481792
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------