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General NPI Number Information
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NPI Number | 1952777963
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Entity Type | Organization
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Legal Business Name | IMPALA PHARMACY INC
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Dates
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Enumeration Date | 08/13/2015
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Last Update Date | 08/13/2015
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Provider Practice Location Address
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Address Line | 11 RIDGE BLVD
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City | BROOKHAVEN
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State | PA
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Zip | 19015-2317
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Country | US
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Telephone | 484-482-6274
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Fax | 484-490-6978
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Provider Business Mailing Address
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Address Line | 11 RIDGE BLVD
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City | BROOKHAVEN
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State | PA
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Zip | 19015-2317
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Country | US
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Telephone | 484-482-6274
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Fax | 484-490-6978
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. VINCENT CANZANESE
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Credential | RPH
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Telephone | 484-482-6274
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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