Healthcare Provider Details

I. General information

NPI: 1164575403
Provider Name (Legal Business Name): WESTGATE PHARMACY RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 HILLSIDE BLVD
LAKEWOOD NJ
08701-3148
US

IV. Provider business mailing address

112 HILLSIDE BLVD
LAKEWOOD NJ
08701-3148
US

V. Phone/Fax

Practice location:
  • Phone: 732-370-2500
  • Fax: 732-230-6939
Mailing address:
  • Phone: 732-370-2500
  • Fax: 732-256-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00670900
License Number StateNJ

VIII. Authorized Official

Name: DAVID SEGAL
Title or Position: MANG
Credential:
Phone: 732-370-2500