=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770685794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLC PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2006
-----------------------------------------------------
Last Update Date | 06/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 570 NEWARK AVENUE
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-653-4093
-----------------------------------------------------
Fax | 201-222-1901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 570 NEWARK AVENUE
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-653-4093
-----------------------------------------------------
Fax | 201-222-1901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE OWNER
-----------------------------------------------------
Name | MR. MARIO GERGES
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 201-653-4093
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00672800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------