Provider Demographics
NPI:1154978120
Name:AMENA, JED-SHERWIN M
Entity type:Individual
Prefix:
First Name:JED-SHERWIN
Middle Name:M
Last Name:AMENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 TORRESDALE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19135-1313
Mailing Address - Country:US
Mailing Address - Phone:267-686-6256
Mailing Address - Fax:
Practice Address - Street 1:7100 TORRESDALE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19135-1313
Practice Address - Country:US
Practice Address - Phone:267-686-6256
Practice Address - Fax:267-686-6244
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP447767183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103086010001Medicaid