=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275929150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCIENCE GLADIATORS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2015
-----------------------------------------------------
Last Update Date | 09/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 LIVINGSTON ST
-----------------------------------------------------
City | NORTHVALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07647-1738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-767-2621
-----------------------------------------------------
Fax | 201-297-7720
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 LIVINGSTON ST STE 106
-----------------------------------------------------
City | NORTHVALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07647-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-322-9090
-----------------------------------------------------
Fax | 201-767-2680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | DAVID YOON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-322-9090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00739300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------