Provider Demographics
NPI:1053624593
Name:TABULA RASA HEALTHCARE GROUP, INC.
Entity type:Organization
Organization Name:TABULA RASA HEALTHCARE GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ORSULA
Authorized Official - Middle Name:V
Authorized Official - Last Name:KNOWLTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MBA
Authorized Official - Phone:215-680-8983
Mailing Address - Street 1:228 STRAWBRIDGE DR
Mailing Address - Street 2:STE 200
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-4600
Mailing Address - Country:US
Mailing Address - Phone:888-974-2763
Mailing Address - Fax:856-273-0135
Practice Address - Street 1:228 STRAWBRIDGE DR
Practice Address - Street 2:STE 200
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-4600
Practice Address - Country:US
Practice Address - Phone:888-974-2763
Practice Address - Fax:856-273-0135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TABULA RASA HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-26
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1137283336L0003X
DEA9-00015763336L0003X
NC123943336L0003X
IL540195523336L0003X
IN64001638A3336L0003X
MDP069493336L0003X
LAPHY.007106-NR3336L0003X
MTPHA-MOPA-LIC-400403336L0003X
MI53010106463336L0003X
KS22-1006353336L0003X
COOSP.00059483336L0003X
MN2651093336L0003X
FLPH293933336L0003X
IA44863336L0003X
NE9083336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1053624593Medicaid
CO22470760Medicaid
NJ0253316Medicaid
2125914OtherPK
PA102567985001Medicaid
IL1053624593Medicaid