MEDICARE: MK GLAM RX

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1477228906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MK GLAM RX

Provider Business Mailing Address
First Line	:	2290 W OREGON AVE # 1026
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4197
Country	:	US
Telephone Number	:	267-399-0081
Fax Number	:

Provider Business Practice Location Address
First Line	:	2290 W OREGON AVE # 1026
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4197
Country	:	US
Telephone Number	:	267-399-0081
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MAEYONNI WESTBROOK
Credential	:
Telephone Number	:	215-609-2907

Provider Enumeration Date	:	08/16/2021
Last Update Date	:	08/16/2021

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Directions to “MK GLAM RX ” Practice Location

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