=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487060109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHREE GANESH PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2014
-----------------------------------------------------
Last Update Date | 02/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 MAIN AVE
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-4952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-471-9100
-----------------------------------------------------
Fax | 973-471-9900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 MAIN AVE
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-4952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-471-9100
-----------------------------------------------------
Fax | 973-471-9900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | JIGNA PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 979-471-9100
-----------------------------------------------------
=====================================================
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 | 28RS00734000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------