MEDICARE: BARON 11 OF MOONACHIE INC

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	28RS00464300	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	3123964	OTHER	NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1548271182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BARON 11 OF MOONACHIE INC

Provider Business Mailing Address
First Line	:	91 MOONACHIE RD
Second Line	:
City	:	MOONACHIE
State	:	NJ
Zip	:	07074-1016
Country	:	US
Telephone Number	:	201-641-1110
Fax Number	:	201-659-3113

Provider Business Practice Location Address
First Line	:	91 MOONACHIE RD
Second Line	:
City	:	MOONACHIE
State	:	NJ
Zip	:	07074-1016
Country	:	US
Telephone Number	:	201-641-1110
Fax Number	:	201-659-3113

Authorized Official
Title or Position	:	PRES
Name	:	RUDOLF TRIVIGNO
Credential	:
Telephone Number	:	201-641-1110

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	11/15/2011

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Directions to “BARON 11 OF MOONACHIE INC ” Practice Location

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