Healthcare Provider Details

I. General information

NPI: 1528474665
Provider Name (Legal Business Name): OLD STONE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 W GRAND AVE SUITE 6
MONTVALE NJ
07645-2100
US

IV. Provider business mailing address

28 W GRAND AVE SUITE 6
MONTVALE NJ
07645-2100
US

V. Phone/Fax

Practice location:
  • Phone: 201-746-4555
  • Fax: 201-745-4989
Mailing address:
  • Phone: 201-746-4555
  • Fax: 201-745-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00734600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number28RS00734600
License Number StateNJ

VIII. Authorized Official

Name: TARA FRICKE
Title or Position: PHARMACIST
Credential:
Phone: 201-746-4555