=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467516765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MLK PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2006
-----------------------------------------------------
Last Update Date | 09/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 173 MARTIN LUTHER KING JR DR
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07305-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-332-7032
-----------------------------------------------------
Fax | 201-333-0348
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 173 MARTIN LUTHER KING JR DR
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07305-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ABDUL BARI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-332-7032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00641000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------