MEDICARE: MR. BRADLEY EVAN TABAAC RPH

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	183500000X	Pharmacist	RP032545L	PA

General Provider Information

NPI Number	:	1528685864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRADLEY EVAN TABAAC RPH

Provider Business Mailing Address
First Line	:	508 LEON CIR
Second Line	:
City	:	LANGHORNE
State	:	PA
Zip	:	19053-1955
Country	:	US
Telephone Number	:	215-869-4242
Fax Number	:	215-425-5594

Provider Business Practice Location Address
First Line	:	2258 N FRONT ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-3714
Country	:	US
Telephone Number	:	215-425-5230
Fax Number	:	215-425-5594

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2020
Last Update Date	:	07/02/2020

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