Healthcare Provider Details

I. General information

NPI: 1922113703
Provider Name (Legal Business Name): INSERRA SUPERMARKET INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 LIVINGSTON ST
NORTHVALE NJ
07647-1910
US

IV. Provider business mailing address

PO BOX 8500-51250
PHILADELPHIA PA
19178-0001
US

V. Phone/Fax

Practice location:
  • Phone: 201-641-4998
  • Fax: 201-784-3880
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberRS004539
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MELISSA FIGUEROA RIVERA
Title or Position: THIRD PARTY ADMINISTRATOR
Credential:
Phone: 732-521-8439