=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205871027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PASSAIC COMMUNITY PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 339 PASSAIC STREET
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-471-0160
-----------------------------------------------------
Fax | 973-471-0110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 CHRISTOPHER COURT
-----------------------------------------------------
City | MATAWAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-471-0160
-----------------------------------------------------
Fax | 973-471-0110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | SAM AWAD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-471-0160
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 28RS00592100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------