Healthcare Provider Details

I. General information

NPI: 1174663538
Provider Name (Legal Business Name): VILLAGE SUPER MARKET OF NJ, L.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 E HANOVER AVE
CEDAR KNOLLS NJ
07927
US

IV. Provider business mailing address

733 MOUNTAIN AVE
SPRINGFIELD NJ
07081-3223
US

V. Phone/Fax

Practice location:
  • Phone: 973-539-3907
  • Fax: 973-538-3919
Mailing address:
  • Phone: 973-539-3907
  • Fax: 973-538-3919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberRS003355
License Number StateNJ

VIII. Authorized Official

Name: MELISSA FIGUEROA RIVERA
Title or Position: THIRD PARTY ADMINISTRATOR
Credential:
Phone: 732-521-8448