Healthcare Provider Details

I. General information

NPI: 1225130354
Provider Name (Legal Business Name): FOURTH AVE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 ROSEVILLE AVE
NEWARK NJ
07107-1757
US

IV. Provider business mailing address

329 ROSEVILLE AVE
NEWARK NJ
07107-1757
US

V. Phone/Fax

Practice location:
  • Phone: 973-483-3872
  • Fax: 973-483-6956
Mailing address:
  • Phone: 973-483-3872
  • Fax: 973-483-6956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00335200
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AYUSH GAJERA
Title or Position: PHARMACIST
Credential:
Phone: 973-483-3872