Healthcare Provider Details

I. General information

NPI: 1023053469
Provider Name (Legal Business Name): PLYMOUTH PARK PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 10/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 12 SADDLE RIVER RD
FAIR LAWN NJ
07410-5786
US

IV. Provider business mailing address

11 12 SADDLE RIVER RD
FAIR LAWN NJ
07410-5786
US

V. Phone/Fax

Practice location:
  • Phone: 201-797-0006
  • Fax: 201-797-0007
Mailing address:
  • Phone: 201-797-0006
  • Fax: 201-797-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS001207900
License Number StateNJ

VIII. Authorized Official

Name: BRYAN SCOTT PISKADLO
Title or Position: PRESIDENT
Credential:
Phone: 201-797-0006