1295878932 NPI number — STATE STREET PHARMACY

Table of content: (NPI 1295878932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295878932 NPI number — STATE STREET PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE STREET PHARMACY
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:
Provider Other Organization Name Type Code:
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:
1295878932
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLINGSWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08108-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-858-9292
Provider Business Mailing Address Fax Number:
856-858-7286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
735 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08102-1827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-541-3450
Provider Business Practice Location Address Fax Number:
856-541-3452
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEHRMAN
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
E
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
215-927-6700

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  RS02998 , 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: 3124625 . This is a "NCPDP" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: RS02998 . This is a "STATE LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 4328205 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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