Provider Demographics
NPI:1962560565
Name:SUBURBAN BUSTLETON PHARMACY INC.
Entity type:Organization
Organization Name:SUBURBAN BUSTLETON PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DZIERZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-673-0994
Mailing Address - Street 1:10875 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3301
Mailing Address - Country:US
Mailing Address - Phone:215-673-0994
Mailing Address - Fax:215-969-6176
Practice Address - Street 1:10875 BUSTLETON AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3301
Practice Address - Country:US
Practice Address - Phone:215-673-0994
Practice Address - Fax:215-969-6176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP412433L333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014348470001Medicaid