1710036975 NPI number — SOWADAUTH, INC.

Table of content: (NPI 1710036975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710036975 NPI number — SOWADAUTH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOWADAUTH, INC.
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:
ROCK RIDGE 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:
1710036975
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 605
Provider Second Line Business Mailing Address:
191 ROCK ROAD
Provider Business Mailing Address City Name:
GLEN ROCK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07452-0605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-444-4190
Provider Business Mailing Address Fax Number:
201-444-2698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
191 ROCK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ROCK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07452-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-444-4190
Provider Business Practice Location Address Fax Number:
201-444-2698
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KOPACKI
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
201-444-4190

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  4873 , 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: 6239609 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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