Healthcare Provider Details

I. General information

NPI: 1285757674
Provider Name (Legal Business Name): ALEKSANDAR MIRKOVIC R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 12/05/2020
Certification Date: 12/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1098 MANTUA PIKE
WENONAH NJ
08090-1124
US

IV. Provider business mailing address

1098 MANTUA PIKE
WENONAH NJ
08090-1124
US

V. Phone/Fax

Practice location:
  • Phone: 856-464-1077
  • Fax: 856-415-0826
Mailing address:
  • Phone: 856-464-1077
  • Fax: 856-415-0826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP443247
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302029928
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03258600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: