Provider Demographics
NPI:1073069779
Name:PREMIER SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:PREMIER SPECIALTY PHARMACY LLC
Other - Org Name:PREMIER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:POLINA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLIAKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-683-8647
Mailing Address - Street 1:101 PARK AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-3795
Mailing Address - Country:US
Mailing Address - Phone:201-683-8647
Mailing Address - Fax:201-683-8648
Practice Address - Street 1:101 PARK AVE
Practice Address - Street 2:STE 2
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-3795
Practice Address - Country:US
Practice Address - Phone:201-683-8647
Practice Address - Fax:201-683-8648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00751600333600000X
3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacyGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164428OtherPK