MEDICARE: JERSEY APOTHECARY 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	3336C0003X	Community/Retail Pharmacy	28RS00632600	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	2143467	OTHER		PK

General Provider Information

NPI Number	:	1407833122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERSEY APOTHECARY INC

Provider Business Mailing Address
First Line	:	286 CENTRAL AVE
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07307-3013
Country	:	US
Telephone Number	:	201-656-4392
Fax Number	:	201-420-8399

Provider Business Practice Location Address
First Line	:	286 CENTRAL AVE
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07307-3013
Country	:	US
Telephone Number	:	201-656-4392
Fax Number	:	201-420-8399

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVE TAN
Credential	:
Telephone Number	:	973-943-1231

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	07/24/2014

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