1154432169 NPI number — SILVERTON PHARMACY LLC

Table of content: (NPI 1154432169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154432169 NPI number — SILVERTON PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SILVERTON PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SILVERTON PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154432169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1824 HOOPER AVE. SILVERTON PHARMACY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOMS RIVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-255-4788
Provider Business Mailing Address Fax Number:
732-255-3249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1824 HOOPER AVE. SILVERTON PHARMACY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOMS RIVER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-255-3121
Provider Business Practice Location Address Fax Number:
732-255-3249
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
JAY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY OWNER
Authorized Official Telephone Number:
732-255-3121

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  28RS00020800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0577260 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3101425 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4288602 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".