Provider Demographics
NPI:1053650119
Name:LAWNSIDE SHOPRITE LLC
Entity Type:Organization
Organization Name:LAWNSIDE SHOPRITE LLC
Other - Org Name:SHOPRITE PHARMACY OF LAWNSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8439
Mailing Address - Street 1:1230 BLACKWOOD CLEMENTON RD
Mailing Address - Street 2:
Mailing Address - City:CLEMENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-5632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 WHITE HORSE PIKE N
Practice Address - Street 2:
Practice Address - City:LAWNSIDE
Practice Address - State:NJ
Practice Address - Zip Code:08045-1128
Practice Address - Country:US
Practice Address - Phone:856-627-6501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-11
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
7244150001Medicare NSC