Basic Information
| Provider Information | |||||||||
| NPI: | 1306216866 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENCLARA PHARMACIA, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ENCLARA PHARMACIA, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 1800 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778827822 | ||||||||
| FaxNumber: | 2152821587 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 1800 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778827822 | ||||||||
| FaxNumber: | 2152821587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2015 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VALENTINE | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANGER, LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 7329961187 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336M0002X | PP481458 | PA | N | Suppliers | Pharmacy | Mail Order Pharmacy | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2154057 | 01 | PK | OTHER |