Provider Demographics
NPI:1902150394
Name:5 STAR PHARMACY & MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:5 STAR PHARMACY & MEDICAL SUPPLY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-997-1220
Mailing Address - Street 1:209 2ND STREET PIKE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3833
Mailing Address - Country:US
Mailing Address - Phone:215-355-2004
Mailing Address - Fax:215-355-6001
Practice Address - Street 1:209 2ND STREET PIKE
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3833
Practice Address - Country:US
Practice Address - Phone:215-355-2004
Practice Address - Fax:215-355-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4823293336C0003X, 3336C0003X, 3336C0003X
PAPET MED PP4823293336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148058OtherPK
PA1029812060001Medicaid