Healthcare Provider Details

I. General information

NPI: 1679558597
Provider Name (Legal Business Name): PASSAIC PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 MONROE ST
PASSAIC NJ
07055-5209
US

IV. Provider business mailing address

291 MONROE ST
PASSAIC NJ
07055-5209
US

V. Phone/Fax

Practice location:
  • Phone: 973-777-3121
  • Fax: 973-777-3181
Mailing address:
  • Phone: 973-777-3121
  • Fax: 973-777-3181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number28RS00414400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number28RS00414400
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number28RS00414400
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00414400
License Number StateNJ

VIII. Authorized Official

Name: MR. ANTONIO ORESTES RODRIGUEZ
Title or Position: PRESIDENT
Credential:
Phone: 973-777-3121