=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063843241
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTICARE REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2013
-----------------------------------------------------
Last Update Date | 02/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 W JIMMIE LEEDS RD
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08240-9102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-404-4833
-----------------------------------------------------
Fax | 609-404-4834
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 W JIMMIE LEEDS RD
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08240-9102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-404-4833
-----------------------------------------------------
Fax | 609-404-4834
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AVP PHARMACY/MEDICINE
-----------------------------------------------------
Name | SANDRA GARRETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-449-4336
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00730300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------