Provider Demographics
NPI:1528048873
Name:NICE PHARMACY
Entity type:Organization
Organization Name:NICE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:MATHEW
Authorized Official - Last Name:POLICARE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:215-425-0100
Mailing Address - Street 1:110 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-2207
Mailing Address - Country:US
Mailing Address - Phone:215-425-0100
Mailing Address - Fax:215-425-2524
Practice Address - Street 1:110 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-2207
Practice Address - Country:US
Practice Address - Phone:215-425-0100
Practice Address - Fax:215-425-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP415588L333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39-76581OtherNCPDP NUMBER
PA0017694730001Medicaid
PAPP-415588LOtherSTATE PHARMACY #
PAPP-415588LOtherSTATE PHARMACY #
PAPP-415588LOtherSTATE PHARMACY #