MEDICARE: TACONY 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PP482617	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2157985	OTHER		PK

General Provider Information

NPI Number	:	1033578505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TACONY PHARMACY INC

Provider Business Mailing Address
First Line	:	7100 TORRESDALE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19135
Country	:	US
Telephone Number	:	267-686-6256
Fax Number	:

Provider Business Practice Location Address
First Line	:	7100 TORRESDALE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19135-1313
Country	:	US
Telephone Number	:	267-686-6256
Fax Number	:	267-686-6244

Authorized Official
Title or Position	:	OWNER
Name	:	KOFI GBOMITA
Credential	:
Telephone Number	:	267-686-6256

Provider Enumeration Date	:	02/12/2016
Last Update Date	:	03/03/2022

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