=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952704165
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRVIEW PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2014
-----------------------------------------------------
Last Update Date | 02/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 ANDERSON AVE
-----------------------------------------------------
City | FAIRVIEW
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07022-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-840-8049
-----------------------------------------------------
Fax | 201-945-0816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 ANDERSON AVE
-----------------------------------------------------
City | FAIRVIEW
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07022-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-840-8049
-----------------------------------------------------
Fax | 201-945-0816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PIC, AO
-----------------------------------------------------
Name | DWIGHT MONTFORT
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 201-840-8049
-----------------------------------------------------
=====================================================
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 | 28RS00736100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------