Healthcare Provider Details

I. General information

NPI: 1336124593
Provider Name (Legal Business Name): 21ST AVE PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 21ST AVE
PATERSON NJ
07501-3642
US

IV. Provider business mailing address

357 21ST AVE
PATERSON NJ
07501-3642
US

V. Phone/Fax

Practice location:
  • Phone: 973-742-1235
  • Fax: 973-742-0353
Mailing address:
  • Phone: 973-742-1235
  • Fax: 973-742-0353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RS00334800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number28RS003348
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS003348
License Number StateNJ

VIII. Authorized Official

Name: MR. ANTONIO ORESTES RODRIGUEZ
Title or Position: PRESIDENT
Credential:
Phone: 973-742-1235