MEDICARE: RUDOLF TRIVIGNO JR. RPH

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	183500000X	Pharmacist	28RI02279800	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	28RI02279800	OTHER		BOARD OF PHARMACY

General Provider Information

NPI Number	:	1811270309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUDOLF TRIVIGNO JR. RPH

Provider Business Mailing Address
First Line	:	91 MOONACHIE ROAD
Second Line	:
City	:	MOONACHIE
State	:	NJ
Zip	:	07074
Country	:	US
Telephone Number	:	201-835-0784
Fax Number	:

Provider Business Practice Location Address
First Line	:	91 MOONACHIE RD
Second Line	:
City	:	MOONACHIE
State	:	NJ
Zip	:	07074-1016
Country	:	US
Telephone Number	:	201-641-1110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2011
Last Update Date	:	09/21/2011

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