MEDICARE: HILLRISE 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	PP482646	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2160216	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154778983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HILLRISE PHARMACY LLC

Provider Business Mailing Address
First Line	:	4240 N BROAD ST UNIT B
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19140-1908
Country	:	US
Telephone Number	:	215-403-7300
Fax Number	:	267-335-3937

Provider Business Practice Location Address
First Line	:	4240 N BROAD ST UNIT B
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19140-1908
Country	:	US
Telephone Number	:	215-403-7300
Fax Number	:	267-335-3937

Authorized Official
Title or Position	:	MEMBER/OWNER
Name	:	OMOTAYO BADEJOKO
Credential	:	B PHARM
Telephone Number	:	484-326-1877

Provider Enumeration Date	:	05/23/2016
Last Update Date	:	07/27/2018

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