=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003468919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARRYS DREAM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2019
-----------------------------------------------------
Last Update Date | 07/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1776 N OLDEN AVE
-----------------------------------------------------
City | EWING
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08638-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-251-4500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 MOUNTAINVIEW RD
-----------------------------------------------------
City | MOUNT LAUREL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08054-4729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-251-4500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HITENDRAKUMAR VITTHALBHAI PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-251-4500
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------