MEDICARE: GREENVILLE PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy		NJ

General Provider Information

NPI Number	:	1356855480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENVILLE PHARMACY LLC

Provider Business Mailing Address
First Line	:	1850 JOHN F KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07305-2122
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1850 JOHN F KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07305-2122
Country	:	US
Telephone Number	:	201-433-8002
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EDWARD MOSSAD
Credential	:
Telephone Number	:	201-433-8002

Provider Enumeration Date	:	11/28/2017
Last Update Date	:	11/28/2017

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