Provider Demographics
NPI:1568631372
Name:RENAISSANCE FAMILY PHARMACY INC
Entity type:Organization
Organization Name:RENAISSANCE FAMILY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KASHUBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-798-4801
Mailing Address - Street 1:2618 PHILADELPHIA PIKE
Mailing Address - Street 2:
Mailing Address - City:CLAYMONT
Mailing Address - State:DE
Mailing Address - Zip Code:19703-2504
Mailing Address - Country:US
Mailing Address - Phone:302-798-4801
Mailing Address - Fax:302-798-4804
Practice Address - Street 1:2618 PHILADELPHIA PIKE
Practice Address - Street 2:
Practice Address - City:CLAYMONT
Practice Address - State:DE
Practice Address - Zip Code:19703-2504
Practice Address - Country:US
Practice Address - Phone:302-798-4801
Practice Address - Fax:302-798-4804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA300008973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0844919OtherNCPDP PROVIDER IDENTIFICATION NUMBER