Healthcare Provider Details

I. General information

NPI: 1396870986
Provider Name (Legal Business Name): IMPRIMISRX NJ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 ROUTE 46 STE 4
LEDGEWOOD NJ
07852-9720
US

IV. Provider business mailing address

1000 AVIARA DR STE 220
CARLSBAD CA
92011-4218
US

V. Phone/Fax

Practice location:
  • Phone: 844-446-6979
  • Fax: 855-405-4669
Mailing address:
  • Phone: 858-704-4040
  • Fax: 858-345-1745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number28RS00593300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00593300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number28RS00593300
License Number StateNJ

VIII. Authorized Official

Name: MR. ANDREW RICHARD BOLL
Title or Position: SECRETARY & CFO
Credential:
Phone: 858-704-4040