MEDICARE: GOODHEART 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	3336C0004X	Compounding Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy
4	3336C0003X	Community/Retail Pharmacy	PP482140	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	2130575	OTHER		PK

General Provider Information

NPI Number	:	1659665271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODHEART PHARMACY INC

Provider Business Mailing Address
First Line	:	4835 WOODLAND AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-4433
Country	:	US
Telephone Number	:	215-724-3300
Fax Number	:

Provider Business Practice Location Address
First Line	:	4835 WOODLAND AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-4433
Country	:	US
Telephone Number	:	215-724-3300
Fax Number	:	215-724-3301

Authorized Official
Title or Position	:	PHARMACIST INCHARGE
Name	:	OBIOMA AGUOCHA
Credential	:
Telephone Number	:	215-724-3300

Provider Enumeration Date	:	05/31/2011
Last Update Date	:	08/16/2016

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Directions to “GOODHEART PHARMACY INC ” Practice Location

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