Healthcare Provider Details

I. General information

NPI: 1508801713
Provider Name (Legal Business Name): 200 CHESTNUT ST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CHESTNUT ST
ROSELLE PARK NJ
07204-2263
US

IV. Provider business mailing address

200 CHESTNUT ST
ROSELLE PARK NJ
07204-2263
US

V. Phone/Fax

Practice location:
  • Phone: 908-245-1396
  • Fax: 908-245-1616
Mailing address:
  • Phone: 908-245-1396
  • Fax: 908-245-1616

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 Number28RS00660900
License Number StateNJ

VIII. Authorized Official

Name: SANJAY SHAH
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 908-245-1396