=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053412585
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA NUEVA MERCEDES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 05/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 RIVER ST
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07524-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-279-2800
-----------------------------------------------------
Fax | 973-279-2197
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 RIVER ST
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07524-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-279-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER/MANAGER
-----------------------------------------------------
Name | MISS BLANCA GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-279-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00328400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------