Organization
TRACEMARK PHARMACY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BEVIS E VANTERPOOL PHARM.D. (PHARMACY OWNER)
(215) 668-4494
Entity
Organization
Contact information
Practice address
4839 N BROAD ST, PHILADELPHIA, PA 19141-2107
(215) 324-0800
(215) 324-0803
Mailing address
4839 N BROAD ST, PHILADELPHIA, PA 19141-2107
(215) 324-0800
(215) 324-0803
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
PP481991
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1024349890001
—
PA
Enumeration date
04/28/2010
Last updated
04/28/2010
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