Provider Demographics
NPI:1194126128
Name:PRIMARY CHOICE PHARMACY LLC
Entity type:Organization
Organization Name:PRIMARY CHOICE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMILOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-782-5974
Mailing Address - Street 1:5575 OLD YORK RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141
Mailing Address - Country:US
Mailing Address - Phone:215-437-9043
Mailing Address - Fax:215-437-9045
Practice Address - Street 1:5575 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141
Practice Address - Country:US
Practice Address - Phone:215-437-9043
Practice Address - Fax:215-437-9045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP482510332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029774280002Medicaid
PA1194126128OtherDURABLE MEDICAL EQUIPMENT
PA1029774280002Medicaid