Healthcare Provider Details

I. General information

NPI: 1811704133
Provider Name (Legal Business Name): 295 CENTRAL AVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 CENTRAL AVE
JERSEY CITY NJ
07307-2996
US

IV. Provider business mailing address

295 CENTRAL AVE
JERSEY CITY NJ
07307-2996
US

V. Phone/Fax

Practice location:
  • Phone: 201-653-1200
  • Fax: 201-653-1205
Mailing address:
  • Phone: 201-653-1200
  • Fax: 201-653-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DIPAK J SHAH
Title or Position: PIC
Credential:
Phone: 201-653-1200