Provider Demographics
NPI:1003135195
Name:LEGACY DRUGSTORE INC
Entity Type:Organization
Organization Name:LEGACY DRUGSTORE INC
Other - Org Name:LEGACY DRUGSTORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GURDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-352-0050
Mailing Address - Street 1:400 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-3502
Mailing Address - Country:US
Mailing Address - Phone:908-352-0050
Mailing Address - Fax:908-352-0075
Practice Address - Street 1:400 S BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-3502
Practice Address - Country:US
Practice Address - Phone:908-352-0050
Practice Address - Fax:908-352-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS007036003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125679OtherPK
2125679OtherPK