1205933132 NPI number — PROFESSIONAL COMPOUNDING CENTER OF SOUTH JERSEY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205933132 NPI number — PROFESSIONAL COMPOUNDING CENTER OF SOUTH JERSEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL COMPOUNDING CENTER OF SOUTH JERSEY
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:
STOKES 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:
1205933132
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:
639 STOKES RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08055-3003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
639 STOKES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08055-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-654-5222
Provider Business Practice Location Address Fax Number:
609-654-5899
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCVEY
Authorized Official First Name:
EMMETT
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST OWNER
Authorized Official Telephone Number:
609-654-5222

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  28RS00619800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 3145085 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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