Healthcare Provider Details

I. General information

NPI: 1154374338
Provider Name (Legal Business Name): MADISON PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W FRONT ST
PLAINFIELD NJ
07060-1120
US

IV. Provider business mailing address

400 W FRONT ST
PLAINFIELD NJ
07060-1120
US

V. Phone/Fax

Practice location:
  • Phone: 908-412-1333
  • Fax: 908-412-6555
Mailing address:
  • Phone: 908-412-1333
  • Fax: 908-412-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00660100
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier0208515
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier2055932
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: MADHU RACHAMALLU
Title or Position: OWNER
Credential:
Phone: 908-412-1333