Provider Demographics
NPI:1861561714
Name:BOOTHWYN PHARMACY LLC
Entity type:Organization
Organization Name:BOOTHWYN PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MICOLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-485-1130
Mailing Address - Street 1:221 GALE LN
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348
Mailing Address - Country:US
Mailing Address - Phone:800-476-7496
Mailing Address - Fax:610-497-4371
Practice Address - Street 1:221 GALE LN
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-1735
Practice Address - Country:US
Practice Address - Phone:800-476-7496
Practice Address - Fax:610-497-4371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X, 3336H0001X, 3336L0003X, 3336S0011X
PAPP410228L3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7P228LMedicaid
IN200887500AMedicaid
2082253OtherPK
KY7100087360Medicaid
NE0936230001Medicaid
PA0014804650002Medicaid
IN200887500AMedicaid