=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073647012
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAYAK RAM GUPTA R.PH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 543 GRAND AVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-4934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-568-9378
-----------------------------------------------------
Fax | 201-568-9226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 GREENVIEW DR
-----------------------------------------------------
City | PEQUANNOCK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07440-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-694-7020
-----------------------------------------------------
Fax | 201-568-9226
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 28RI01593200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------