Healthcare Provider Details

I. General information

NPI: 1306951173
Provider Name (Legal Business Name): VILLAGE SUPER MARKET OF NJ LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 MORRIS TPKE
SPRINGFIELD NJ
07081-1514
US

IV. Provider business mailing address

733 MOUNTAIN AVE
SPRINGFIELD NJ
07081-3223
US

V. Phone/Fax

Practice location:
  • Phone: 973-467-3162
  • Fax: 973-258-1893
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberRS003147
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MELISSA FIGUEROA RIVERA
Title or Position: THIRD PARTY ADMINISTRATOR
Credential:
Phone: 732-521-8448