=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003162041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARLBORO VILLAGE PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2012
-----------------------------------------------------
Last Update Date | 12/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 SCHOOL RD W
-----------------------------------------------------
City | MARLBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07746-1507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-617-6060
-----------------------------------------------------
Fax | 732-719-2323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 SCHOOL RD W
-----------------------------------------------------
City | MARLBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07746-1507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-617-6060
-----------------------------------------------------
Fax | 732-719-2323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | STANSISLAV HISH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-617-6060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00726200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------