Healthcare Provider Details

I. General information

NPI: 1003561655
Provider Name (Legal Business Name): AJ PHARMACY STORE 02
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2022
Last Update Date: 09/08/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 SMITHFIELD RD
NORTH PROVIDENCE RI
02904-4266
US

IV. Provider business mailing address

1017 SMITH ST
PROVIDENCE RI
02908-2747
US

V. Phone/Fax

Practice location:
  • Phone: 401-366-2800
  • Fax:
Mailing address:
  • Phone: 401-366-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHARLES AGWUNOBI
Title or Position: OWNER
Credential:
Phone: 401-499-5427