MEDICARE: RITE AID OF PENNSYLVANIA LLC

Medicare Provider Information

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
2	3336C0003X	Community/Retail Pharmacy	PP412144L	PA

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	3940675	OTHER	OTHER ID NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1275623399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RITE AID OF PENNSYLVANIA LLC

Provider Business Mailing Address
First Line	:	200 NEWBERRY COMMONS
Second Line	:
City	:	ETTERS
State	:	PA
Zip	:	17319-9363
Country	:	US
Telephone Number	:	717-761-2633
Fax Number	:	717-975-8659

Provider Business Practice Location Address
First Line	:	8130 ROOSEVELT BOULEVARD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-2911
Country	:	US
Telephone Number	:	215-331-0160
Fax Number	:

Authorized Official
Title or Position	:	MANAGER ONLINE ADJUDICATION
Name	:	JENNIFER ZOREK
Credential	:
Telephone Number	:	717-975-5937

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	08/07/2020

8104 ROOSEVELT BLVD
PHILADELPHIA, PA
19152-2911

Practice Phone: 215-543-1125
Practice Fax: