Healthcare Provider Details

I. General information

NPI: 1235679846
Provider Name (Legal Business Name): REVERENCE DISCOUNT PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 S MAIN ST
PLEASANTVILLE NJ
08232-3618
US

IV. Provider business mailing address

5 MOONLIGHT DR
EGG HARBOR TWP NJ
08234-4927
US

V. Phone/Fax

Practice location:
  • Phone: 609-445-4423
  • Fax: 609-445-4423
Mailing address:
  • Phone: 609-904-2540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: WIDLYNE RUFFIN
Title or Position: PHARMACIST
Credential:
Phone: 609-445-4423