Healthcare Provider Details

I. General information

NPI: 1548249717
Provider Name (Legal Business Name): TERRACE APOTHECARY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 TERRACE ST
HAWORTH NJ
07641-1835
US

IV. Provider business mailing address

169 TERRACE ST
HAWORTH NJ
07641-1835
US

V. Phone/Fax

Practice location:
  • Phone: 201-384-7171
  • Fax: 201-384-4433
Mailing address:
  • Phone: 201-384-7171
  • Fax: 201-384-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00478500
License Number StateNJ

VIII. Authorized Official

Name: MR. WESTLEY V WALLER III
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 201-384-7171