Healthcare Provider Details

I. General information

NPI: 1538656582
Provider Name (Legal Business Name): EZ PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 LINDEN ST
HACKENSACK NJ
07601
US

IV. Provider business mailing address

57 LINDEN ST
HACKENSACK NJ
07601-3555
US

V. Phone/Fax

Practice location:
  • Phone: 201-968-5960
  • Fax: 201-968-5261
Mailing address:
  • Phone: 201-968-5260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00763900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: EDUARD ILYASOV
Title or Position: PIC
Credential:
Phone: 201-968-5260