Healthcare Provider Details

I. General information

NPI: 1538557178
Provider Name (Legal Business Name): OBENG PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 MARTIN LUTHER KING JR BLVD
NEWARK NJ
07102-1186
US

IV. Provider business mailing address

671 MARTIN LUTHER KING JR BLVD
NEWARK NJ
07102-1186
US

V. Phone/Fax

Practice location:
  • Phone: 862-237-7601
  • Fax: 862-237-7603
Mailing address:
  • Phone: 862-237-7601
  • Fax: 862-237-7603

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 Number28RS00737900
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ADJE KOFFI
Title or Position: CEO
Credential:
Phone: 862-237-7601