MEDICARE: PROFILE SHOP, 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	332B00000X	Durable Medical Equipment & Medical Supplies	6000005802	PA

General Provider Information

NPI Number	:	1205837291
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFILE SHOP, INC.

Provider Business Mailing Address
First Line	:	3300 TILLMAN DR STE 101
Second Line	:
City	:	BENSALEM
State	:	PA
Zip	:	19020-2071
Country	:	US
Telephone Number	:	215-633-3461
Fax Number	:	215-633-3567

Provider Business Practice Location Address
First Line	:	3300 TILLMAN DR
Second Line	:	SUITE 105
City	:	BENSALEM
State	:	PA
Zip	:	19020-2071
Country	:	US
Telephone Number	:	215-633-3461
Fax Number	:	215-633-3567

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MRS. HEATHER D. MCCLURE
Credential	:	CMF
Telephone Number	:	215-633-3461

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	03/27/2018

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