Healthcare Provider Details

I. General information

NPI: 1801492285
Provider Name (Legal Business Name): THERESA FAIRFAX RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 12/10/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600RT 35 N
SEASIDE HEIGHTS NJ
08751
US

IV. Provider business mailing address

1600 RT 35 N
SEASIDE HEIGHTS NJ
08751
US

V. Phone/Fax

Practice location:
  • Phone: 793-793-2890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI02788100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: