Provider Demographics
NPI:1073592713
Name:MEDI CENTER PHARMACY
Entity Type:Organization
Organization Name:MEDI CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:973-256-0144
Mailing Address - Street 1:993 MCBRIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-2534
Mailing Address - Country:US
Mailing Address - Phone:973-256-0144
Mailing Address - Fax:
Practice Address - Street 1:993 MCBRIDE AVE
Practice Address - Street 2:
Practice Address - City:WEST PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07424-2534
Practice Address - Country:US
Practice Address - Phone:973-256-0144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00615700333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8903204Medicaid
NJ4537290001Medicare ID - Type UnspecifiedCMS MEDICARE NUMBER