1417598095 NPI number — CALDWELL PHARMACY

Table of content: (NPI 1417598095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417598095 NPI number — CALDWELL PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALDWELL PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417598095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 MILL CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW CITY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10956-6441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-300-5897
Provider Business Mailing Address Fax Number:
973-808-1818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
808 BLOOMFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST CALDWELL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07006-6700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-808-1800
Provider Business Practice Location Address Fax Number:
973-808-1818
Provider Enumeration Date:
10/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SAMUEL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
845-300-5897

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0720135 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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