Provider Demographics
NPI:1396163697
Name:SEDGLEY PLAZA PHARMACY INC
Entity type:Organization
Organization Name:SEDGLEY PLAZA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/RPH
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-978-0104
Mailing Address - Street 1:2917 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-5215
Mailing Address - Country:US
Mailing Address - Phone:215-978-0104
Mailing Address - Fax:215-978-0106
Practice Address - Street 1:2917 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-5215
Practice Address - Country:US
Practice Address - Phone:215-978-0104
Practice Address - Fax:215-978-0106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4824023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029290730001Medicaid
2145040OtherPK