MEDICARE: FAMILY PHARMACY OF JESSUP 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	3336C0003X	Community/Retail Pharmacy	PP481064	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3979638	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1487743035
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PHARMACY OF JESSUP INC

Provider Business Mailing Address
First Line	:	128 CONSTITUTION AVE
Second Line	:
City	:	JESSUP
State	:	PA
Zip	:	18434-1218
Country	:	US
Telephone Number	:	570-383-7311
Fax Number	:	570-383-7399

Provider Business Practice Location Address
First Line	:	128 CONSTITUTION AVE
Second Line	:
City	:	JESSUP
State	:	PA
Zip	:	18434-1218
Country	:	US
Telephone Number	:	570-383-7311
Fax Number	:	570-383-7399

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DENNIS DOUGHERTY
Credential	:	RPH
Telephone Number	:	570-499-1900

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	09/12/2012

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