Provider Demographics
NPI:1073511242
Name:FAIRMOUNT PHARMACY INC
Entity type:Organization
Organization Name:FAIRMOUNT PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER AND VP
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLGRAF
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:215-567-0364
Mailing Address - Street 1:1900 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3207
Mailing Address - Country:US
Mailing Address - Phone:215-567-0364
Mailing Address - Fax:215-567-1931
Practice Address - Street 1:1900 GREEN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-3207
Practice Address - Country:US
Practice Address - Phone:215-567-0364
Practice Address - Fax:215-567-1931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP411438L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011124960001Medicaid
2086440OtherPK
0279940001Medicare NSC