Healthcare Provider Details

I. General information

NPI: 1154336790
Provider Name (Legal Business Name): BALD EAGLE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 VALLEY HEALTH PLZ
PARAMUS NJ
07652
US

IV. Provider business mailing address

14 FRANKLIN ST FL 2
BELLEVILLE NJ
07109-1134
US

V. Phone/Fax

Practice location:
  • Phone: 201-225-0970
  • Fax: 201-225-0973
Mailing address:
  • Phone: 973-728-2007
  • Fax: 973-728-1009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number28RI02690900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0093181
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier3193391
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: ANTHONY GUERCIO
Title or Position: MANAGER
Credential:
Phone: 973-728-2007