MEDICARE: 52ND STREET 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	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PP482438	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2144460	OTHER		PK

General Provider Information

NPI Number	:	1306261169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	52ND STREET PHARMACY INC

Provider Business Mailing Address
First Line	:	1226 N 52ND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-4315
Country	:	US
Telephone Number	:	610-704-8594
Fax Number	:	215-921-2708

Provider Business Practice Location Address
First Line	:	1226 N 52ND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-4315
Country	:	US
Telephone Number	:	267-713-7066
Fax Number	:	215-921-2708

Authorized Official
Title or Position	:	OWNER
Name	:	OLALEKAN ABIFARIN
Credential	:
Telephone Number	:	267-713-7066

Provider Enumeration Date	:	03/03/2014
Last Update Date	:	08/01/2014

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Directions to “52ND STREET PHARMACY INC ” Practice Location

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