MEDICARE: CEDAR CARE PHARMACY LLC

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	PP482190	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3996634	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1144590399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR CARE PHARMACY LLC

Provider Business Mailing Address
First Line	:	543 S. 52ND STREET
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143
Country	:	US
Telephone Number	:	215-307-3334
Fax Number	:	215-921-3661

Provider Business Practice Location Address
First Line	:	543 S 52ND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-1532
Country	:	US
Telephone Number	:	215-307-3334
Fax Number	:	215-921-3661

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	UCHECHUKWU NWOBODO
Credential	:
Telephone Number	:	215-307-3334

Provider Enumeration Date	:	01/05/2012
Last Update Date	:	03/17/2012

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