MEDICARE: PETER PAN PHARMACY 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	28RS00323500	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	2056494	OTHER		PK

General Provider Information

NPI Number	:	1508904640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER PAN PHARMACY INC

Provider Business Mailing Address
First Line	:	2125 PARK AVE
Second Line	:
City	:	S PLAINFIELD
State	:	NJ
Zip	:	07080-5401
Country	:	US
Telephone Number	:	908-754-7607
Fax Number	:	908-754-9106

Provider Business Practice Location Address
First Line	:	2125 PARK AVE
Second Line	:
City	:	S PLAINFIELD
State	:	NJ
Zip	:	07080-5401
Country	:	US
Telephone Number	:	908-754-7607
Fax Number	:	908-754-9106

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID KORNAS
Credential	:
Telephone Number	:	908-754-7607

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	08/10/2016

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