=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255675070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENERATION PHARMACY GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2012
-----------------------------------------------------
Last Update Date | 11/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 MAIN RD
-----------------------------------------------------
City | MONTVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07045-9215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-299-2500
-----------------------------------------------------
Fax | 973-909-9935
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 MAIN RD
-----------------------------------------------------
City | MONTVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07045-9215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-299-2500
-----------------------------------------------------
Fax | 973-909-9935
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT, OWNER
-----------------------------------------------------
Name | MRS. LYNDSEE KAY MANNA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-299-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 28RS00722500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------