Provider Demographics
NPI:1003004904
Name:TEXAS ROAD OLD BRIDGE LLC
Entity Type:Organization
Organization Name:TEXAS ROAD OLD BRIDGE LLC
Other - Org Name:TEXAS ROAD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMR
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-723-1101
Mailing Address - Street 1:1183 ENGLISHTOWN RD
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-1319
Mailing Address - Country:US
Mailing Address - Phone:732-723-1101
Mailing Address - Fax:732-723-1141
Practice Address - Street 1:1183 ENGLISHTOWN RD
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-1319
Practice Address - Country:US
Practice Address - Phone:732-723-1101
Practice Address - Fax:732-723-1141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
NJ28RS006743003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0162329Medicaid
2056179OtherPK
6061970001Medicare NSC