1083752216 NPI number — MYSTIC PHARMACY INC

Table of content: (NPI 1083752216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083752216 NPI number — MYSTIC PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYSTIC PHARMACY 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:
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:
1083752216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
972 RADIO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE EGG HARBOR
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-296-0934
Provider Business Mailing Address Fax Number:
609-296-6250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
972 RADIO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE EGG HARBOR
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-296-0934
Provider Business Practice Location Address Fax Number:
609-296-6250
Provider Enumeration Date:
02/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WARD
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
609-296-0934

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  28RS00391800 , 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: 4337905 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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