Healthcare Provider Details

I. General information

NPI: 1972058535
Provider Name (Legal Business Name): JENEV ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 STATE ROUTE 10 UNIT 13
RANDOLPH NJ
07869-2142
US

IV. Provider business mailing address

477 STATE ROUTE 10 UNIT 13
RANDOLPH NJ
07869-2142
US

V. Phone/Fax

Practice location:
  • Phone: 973-775-9818
  • Fax: 973-775-9816
Mailing address:
  • Phone: 973-775-9818
  • Fax: 973-775-9816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00754000
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier2164175
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: DHARMENDRA PATEL
Title or Position: CEO/PHARMACY MANAGER/PIC/AO
Credential: RPH
Phone: 973-220-8098