Provider Demographics
NPI:1124062088
Name:OLD BALTIMORE PIKE APOTHECARY INC
Entity type:Organization
Organization Name:OLD BALTIMORE PIKE APOTHECARY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGLIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:610-869-3200
Mailing Address - Street 1:1011 W BALTIMORE PIKE
Mailing Address - Street 2:STE 109
Mailing Address - City:WEST GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19390-9446
Mailing Address - Country:US
Mailing Address - Phone:610-869-3200
Mailing Address - Fax:610-869-4221
Practice Address - Street 1:1011 W BALTIMORE PIKE
Practice Address - Street 2:STE 109
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-9446
Practice Address - Country:US
Practice Address - Phone:610-869-3200
Practice Address - Fax:610-869-4221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP410390L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000936826Medicaid
2084252OtherPK
2084252OtherPK