Healthcare Provider Details

I. General information

NPI: 1255242723
Provider Name (Legal Business Name): MIKE GEORGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BAY AVE
MONTCLAIR NJ
07042-4837
US

IV. Provider business mailing address

11 WEST DR
BAYONNE NJ
07002-1815
US

V. Phone/Fax

Practice location:
  • Phone: 973-555-5349
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04519800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: