Healthcare Provider Details

I. General information

NPI: 1942023445
Provider Name (Legal Business Name): MAPLE SHADE APOTHECARY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W MAIN ST
MAPLE SHADE NJ
08052-2411
US

IV. Provider business mailing address

25 W MAIN ST
MAPLE SHADE NJ
08052-2411
US

V. Phone/Fax

Practice location:
  • Phone: 856-779-8300
  • Fax:
Mailing address:
  • Phone: 856-779-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MUHAMMAD REHAN KHAN
Title or Position: OWNER
Credential:
Phone: 856-779-8300