1255475711 NPI number — HEALTHY LIFE PHARMACY CORP

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 1255475711 NPI number — HEALTHY LIFE PHARMACY CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHY LIFE PHARMACY CORP
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:
1255475711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
651 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYONNE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07002-4710
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:
651 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYONNE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07002-4710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-339-1200
Provider Business Practice Location Address Fax Number:
201-339-1144
Provider Enumeration Date:
02/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ASHAMALLA
Authorized Official First Name:
ASHRAF
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST AND OWNER
Authorized Official Telephone Number:
201-339-1200

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 28RS00618700 , 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: 9045601 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3144968 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".




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