Provider Demographics
NPI:1003309428
Name:HOLY NAME MEDICAL CENTER INC
Entity Type:Organization
Organization Name:HOLY NAME MEDICAL CENTER INC
Other - Org Name:HOLY NAME PHARMACARE DEPT.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-833-7016
Mailing Address - Street 1:718 TEANECK RD STE 2
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4245
Mailing Address - Country:US
Mailing Address - Phone:201-530-7991
Mailing Address - Fax:201-530-7992
Practice Address - Street 1:718 TEANECK RD STE 2
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666
Practice Address - Country:US
Practice Address - Phone:201-530-7991
Practice Address - Fax:201-530-7992
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLY NAME MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-11
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007623003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177991OtherPK