MEDICARE: BUONADONNA SHOPRITE LLC

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	026563	NY

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	3335456	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1871608653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUONADONNA SHOPRITE LLC

Provider Business Mailing Address
First Line	:	PO BOX 15169
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07192-5169
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1905 SUNRISE HWY
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-6017
Country	:	US
Telephone Number	:	631-666-9377
Fax Number	:	631-666-9330

Authorized Official
Title or Position	:	THIRD PARTY ADMINISTRATOR
Name	:	MELISSA FIGUEROA RIVERA
Credential	:
Telephone Number	:	732-521-8439

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	10/05/2012

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Directions to “BUONADONNA SHOPRITE LLC ” Practice Location

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