MEDICARE: MRS. BRENDA MARY FORD R.PH.

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	RP041804L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RP041804L	OTHER	PA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1104003896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRENDA MARY FORD R.PH.

Provider Business Mailing Address
First Line	:	9141 RIDGE RD
Second Line	:
City	:	GIRARD
State	:	PA
Zip	:	16417-9645
Country	:	US
Telephone Number	:	814-774-8880
Fax Number	:	814-774-1169

Provider Business Practice Location Address
First Line	:	9141 RIDGE RD
Second Line	:
City	:	GIRARD
State	:	PA
Zip	:	16417-9645
Country	:	US
Telephone Number	:	814-774-8880
Fax Number	:	814-774-1169

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2008
Last Update Date	:	01/25/2008

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