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General NPI Number Information
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NPI Number | 1376089706
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Entity Type | Organization
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Legal Business Name | JRE AVE MARIA LLC
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Dates
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Enumeration Date | 01/09/2017
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Last Update Date | 01/24/2020
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Provider Practice Location Address
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Address Line | 124 ROUTE 10 UNIT 4
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City | RANDOLPH
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State | NJ
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Zip | 07869-2415
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Country | US
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Telephone | 973-442-4020
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Fax |
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Provider Business Mailing Address
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Address Line | 124 ROUTE 10
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City | RANDOLPH
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State | NJ
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Zip | 07869-2415
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Country | US
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Telephone | 973-442-4020
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JOHN GHALY
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Credential |
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Telephone | 973-442-4020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State | NJ
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