Healthcare Provider Details

I. General information

NPI: 1255956413
Provider Name (Legal Business Name): BHARATKUMAR RAVJI DHOLARIYA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2020
Last Update Date: 06/13/2020
Certification Date: 06/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 TERHUNE AVE
LODI NJ
07644-2805
US

IV. Provider business mailing address

4 MINERAL SPRING AVE FL 1
PASSAIC NJ
07055-2513
US

V. Phone/Fax

Practice location:
  • Phone: 973-473-2243
  • Fax:
Mailing address:
  • Phone: 973-931-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04092500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: