1215316641 NPI number — PASSAIC VALLEY MEDICAL PHARMACY LLC

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 1215316641 NPI number — PASSAIC VALLEY MEDICAL PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PASSAIC VALLEY MEDICAL 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:
Provider Other Organization Name Type Code:
6
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:
1215316641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1225 MCBRIDE AVE
Provider Second Line Business Mailing Address:
SUITE 112
Provider Business Mailing Address City Name:
WOODLAND PARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07424-3812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-256-0222
Provider Business Mailing Address Fax Number:
973-256-4222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 MCBRIDE AVE
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
WOODLAND PARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07424-3812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-256-0222
Provider Business Practice Location Address Fax Number:
973-256-4222
Provider Enumeration Date:
05/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
AMIN
Authorized Official First Name:
ANUSH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & OFFICER
Authorized Official Telephone Number:
973-869-2820

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  28RS00740700 , 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)





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