Healthcare Provider Details

I. General information

NPI: 1366893851
Provider Name (Legal Business Name): GRAND STREET PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2016
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 GRAND ST
PATERSON NJ
07505-2034
US

IV. Provider business mailing address

351 GRAND ST
PATERSON NJ
07505-2034
US

V. Phone/Fax

Practice location:
  • Phone: 973-374-6480
  • Fax: 973-374-6730
Mailing address:
  • Phone: 973-898-9800
  • Fax: 973-379-9067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number28RS00751800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. RAMESH GAJJAR
Title or Position: OWENER
Credential:
Phone: 973-898-9800