=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023053469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLYMOUTH PARK PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2006
-----------------------------------------------------
Last Update Date | 10/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 12 SADDLE RIVER RD
-----------------------------------------------------
City | FAIR LAWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07410-5786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-797-0006
-----------------------------------------------------
Fax | 201-797-0007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 12 SADDLE RIVER RD
-----------------------------------------------------
City | FAIR LAWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07410-5786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-797-0006
-----------------------------------------------------
Fax | 201-797-0007
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRYAN SCOTT PISKADLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-797-0006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS001207900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------