=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003029083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAINGER'S DRUG STORE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 SOUTH BROAD ST.
-----------------------------------------------------
City | ELIZABETH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07202-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-354-2416
-----------------------------------------------------
Fax | 908-352-0300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 SOUTH BROAD ST.
-----------------------------------------------------
City | ELIZABETH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07202-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-354-2416
-----------------------------------------------------
Fax | 908-352-0300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MYRON JAMES WAINGER
-----------------------------------------------------
Credential | RETIRED RPH
-----------------------------------------------------
Telephone | 908-354-2416
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------