MEDICARE: PACKER APOTHECARY

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	PP482031	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3994173	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1295049625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACKER APOTHECARY

Provider Business Mailing Address
First Line	:	1532 PACKER AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-5407
Country	:	US
Telephone Number	:	267-909-9214
Fax Number	:

Provider Business Practice Location Address
First Line	:	1532 PACKER AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-5407
Country	:	US
Telephone Number	:	267-909-9814
Fax Number	:

Authorized Official
Title or Position	:	MANANGER
Name	:	CHRISTOPHER PAUZANO
Credential	:
Telephone Number	:	267-266-9270

Provider Enumeration Date	:	07/27/2010
Last Update Date	:	02/29/2016

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1760688063 — DR. ELIZABETH DIEM LUONG D.P.M.,
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Practice Location Address:

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1861070153 — MR. VINCENT DIBACCO RPH
Practice Location Address:

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Practice Fax:

Directions to “PACKER APOTHECARY ” Practice Location

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