=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972641009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MPRL PHARMACY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 635 GROVE ST
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-3719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-373-6038
-----------------------------------------------------
Fax | 973-399-4466
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 635 GROVE ST
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-3719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-373-6038
-----------------------------------------------------
Fax | 973-399-4466
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MARC L GREENE
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 973-373-6038
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 28RS00418700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------