Provider Demographics
NPI:1356405930
Name:DAVIDEJA LLC
Entity type:Organization
Organization Name:DAVIDEJA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:267-325-0139
Mailing Address - Street 1:249 S. 52ND STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-9999
Mailing Address - Country:US
Mailing Address - Phone:215-748-0800
Mailing Address - Fax:215-748-1269
Practice Address - Street 1:249 S 52ND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-4148
Practice Address - Country:US
Practice Address - Phone:215-748-0800
Practice Address - Fax:215-748-1269
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVIDEJA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-20
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4813763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3983447OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PA101034939-0001Medicaid
PA101034939-0001Medicaid