MEDICARE: WYCOMBE PHARMACY INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PP481048	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1003954488	OTHER	PA	NPI
3	PP481048	OTHER	PA	LISCENSE
4	3979640	OTHER	PA	NCPDP #

General Provider Information

NPI Number	:	1003954488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYCOMBE PHARMACY INC.

Provider Business Mailing Address
First Line	:	1006 W LEHIGH AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-1640
Country	:	US
Telephone Number	:	215-225-7522
Fax Number	:	215-225-7525

Provider Business Practice Location Address
First Line	:	1006 W LEHIGH AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-1640
Country	:	US
Telephone Number	:	215-225-7522
Fax Number	:	215-225-7525

Authorized Official
Title or Position	:	PHARMACIST & OWNER
Name	:	MR. PAUL CARMEN SCOTA
Credential	:	R.PH.
Telephone Number	:	215-225-7522

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	03/07/2023

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