Healthcare Provider Details

I. General information

NPI: 1760803019
Provider Name (Legal Business Name): TRISTATE WELLNESS PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 DUNHAMS CORNER ROAD
EAST BRUNSWICK NJ
08816
US

IV. Provider business mailing address

51 BRUNSWICK WOODS DRIVE
EAST BRUNSWICK NJ
08816
US

V. Phone/Fax

Practice location:
  • Phone: 908-421-3738
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BASSEM GIRGIS
Title or Position: MANAGING PARTNER
Credential:
Phone: 908-421-3738