=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073914388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPITAL RX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2014
-----------------------------------------------------
Last Update Date | 05/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1985 SWARTHMORE AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-4554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-299-4991
-----------------------------------------------------
Fax | 732-328-2225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1985 SWARTHMORE AVE SUITE 3
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-4554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-299-4991
-----------------------------------------------------
Fax | 732-328-2225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DAVID SEGAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-745-1020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 28RS00735400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------