Basic Information
| Provider Information | |||||||||
| NPI: | 1104862564 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONTCLAIR PHARMACY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MONTCLAIR PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5908 BRECKENRIDGE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133042221 | ||||||||
| FaxNumber: | 8882398423 | ||||||||
| Practice Location | |||||||||
| Address1: | 732 VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | UPPER MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070431521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737442113 | ||||||||
| FaxNumber: | 9737442691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | ALPESH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8133042221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4248210 | 05 | NJ | MEDICAID | 2056802 | 01 | PK | OTHER |