=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639212590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 519 SUMIRAJ CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2007
-----------------------------------------------------
Last Update Date | 12/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 519 BROADWAY
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07104-4132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-482-4968
-----------------------------------------------------
Fax | 973-482-6100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 519 BROADWAY
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07104-4132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-482-4968
-----------------------------------------------------
Fax | 973-482-6100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | CHETAN GANDHI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-482-4968
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00416900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------