=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902045255
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLANDON PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2009
-----------------------------------------------------
Last Update Date | 06/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 ANNA AVE
-----------------------------------------------------
City | BLANDON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19510-9310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-944-8899
-----------------------------------------------------
Fax | 610-944-0888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 ANNA AVE
-----------------------------------------------------
City | BLANDON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19510-9310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-944-8899
-----------------------------------------------------
Fax | 610-944-0888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. ADNAN SHUBBAR
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 610-504-1316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PP481887
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------