Healthcare Provider Details

I. General information

NPI: 1548375322
Provider Name (Legal Business Name): MEDFORD SHOPRITE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 ROUTE 70
MEDFORD NJ
08055-9522
US

IV. Provider business mailing address

1230 BLACKWOOD CLEMENTON RD
CLEMENTON NJ
08021-5632
US

V. Phone/Fax

Practice location:
  • Phone: 609-953-4723
  • Fax: 609-953-4733
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberRS005686
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: MELISSA FIGUEROA RIVERA
Title or Position: THIRD PARTY ADMINISTRATOR
Credential:
Phone: 732-521-8439