Healthcare Provider Details

I. General information

NPI: 1649774159
Provider Name (Legal Business Name): VINCE MOLINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 PIERCE ST
SOMERSET NJ
08873-4185
US

IV. Provider business mailing address

6 BAY ST
PISCATAWAY NJ
08854-4644
US

V. Phone/Fax

Practice location:
  • Phone: 888-319-1818
  • Fax:
Mailing address:
  • Phone: 732-425-5446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03918000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: