Provider Demographics
NPI:1003561655
Name:AJ PHARMACY STORE 02
Entity Type:Organization
Organization Name:AJ PHARMACY STORE 02
Other - Org Name:AJ PHARMACY STORE 02
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:AGWUNOBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-499-5427
Mailing Address - Street 1:1017 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-2747
Mailing Address - Country:US
Mailing Address - Phone:401-366-2800
Mailing Address - Fax:
Practice Address - Street 1:468 SMITHFIELD RD
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-4266
Practice Address - Country:US
Practice Address - Phone:401-366-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AJ PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-12
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI000000Medicaid