MEDICARE: BRADLEY BEACH PAHRAMCY INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	28RS00380000	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2058285	OTHER		PK

General Provider Information

NPI Number	:	1285799619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADLEY BEACH PAHRAMCY INC.

Provider Business Mailing Address
First Line	:	128 MAIN ST
Second Line	:
City	:	BRADLEY BEACH
State	:	NJ
Zip	:	07720-1030
Country	:	US
Telephone Number	:	732-774-7174
Fax Number	:	732-774-7175

Provider Business Practice Location Address
First Line	:	128 MAIN ST
Second Line	:
City	:	BRADLEY BEACH
State	:	NJ
Zip	:	07720-1030
Country	:	US
Telephone Number	:	732-774-7174
Fax Number	:	732-774-7175

Authorized Official
Title or Position	:	PRESIDENT
Name	:	YATMAN KEUNG
Credential	:
Telephone Number	:	732-774-7174

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	11/15/2016

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