=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932254836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INVESTRA CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 06/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 407 SPRINGFIELD AVE
-----------------------------------------------------
City | SUMMIT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07901-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-277-0399
-----------------------------------------------------
Fax | 908-277-1058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 638
-----------------------------------------------------
City | SUMMIT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07902-0638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-277-0399
-----------------------------------------------------
Fax | 908-277-1058
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LOUIS DELROSSO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-277-0399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00337400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------