MEDICARE: SOUSAN 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	3336C0003X	Community/Retail Pharmacy	PP412344L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3914024	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1225028558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUSAN PHARMACY INC

Provider Business Mailing Address
First Line	:	8029 OLD YORK RD
Second Line	:
City	:	ELKINS PARK
State	:	PA
Zip	:	19027-1413
Country	:	US
Telephone Number	:	215-635-4200
Fax Number	:	215-635-3654

Provider Business Practice Location Address
First Line	:	8029 OLD YORK RD
Second Line	:
City	:	ELKINS PARK
State	:	PA
Zip	:	19027-1413
Country	:	US
Telephone Number	:	215-635-4200
Fax Number	:	215-635-3654

Authorized Official
Title or Position	:	OWNER AND PRESIDENT
Name	:	ELLIOTT HAAZ
Credential	:	RPH
Telephone Number	:	215-635-4200

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	07/01/2010

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Directions to “SOUSAN PHARMACY INC ” Practice Location

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