Provider Demographics
NPI:1043583644
Name:PHARMACY OF AMERICA III INC
Entity type:Organization
Organization Name:PHARMACY OF AMERICA III INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SABRI
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:267-237-1188
Mailing Address - Street 1:4654 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-1420
Mailing Address - Country:US
Mailing Address - Phone:215-744-0300
Mailing Address - Fax:215-744-0333
Practice Address - Street 1:217 W LEHIGH AVE
Practice Address - Street 2:STORE #2
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-3421
Practice Address - Country:US
Practice Address - Phone:215-279-7981
Practice Address - Fax:267-687-7662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP4822703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026939530001Medicaid
2133846OtherPK