Healthcare Provider Details

I. General information

NPI: 1801966023
Provider Name (Legal Business Name): RUTGERS, THE STATE UNIV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date: 06/03/2008
Reactivation Date: 08/05/2008

III. Provider practice location address

11 BISHOP PL
NEW BRUNSWICK NJ
08901-1178
US

IV. Provider business mailing address

65 DAVIDSON RD
PISCATAWAY NJ
08854
US

V. Phone/Fax

Practice location:
  • Phone: 732-932-8033
  • Fax: 732-932-8641
Mailing address:
  • Phone: 732-445-2054
  • Fax: 732-445-5922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number28RS00234700
License Number StateNJ

VIII. Authorized Official

Name: JOHN HARABEDIAN
Title or Position: TAX DIRECTOR
Credential: CPR MS-TRX
Phone: 732-445-2054