Healthcare Provider Details

I. General information

NPI: 1699710079
Provider Name (Legal Business Name): MADURA PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N BROADWAY
SOUTH AMBOY NJ
08879-1660
US

IV. Provider business mailing address

115 N BROADWAY
SOUTH AMBOY NJ
08879-1660
US

V. Phone/Fax

Practice location:
  • Phone: 732-721-1732
  • Fax: 732-721-5840
Mailing address:
  • Phone: 732-721-1732
  • Fax: 732-721-5840

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 Number28RS00116700
License Number StateNJ

VIII. Authorized Official

Name: ANNE WOLPIN
Title or Position: AUTH REP
Credential:
Phone: 732-721-1732