Provider Demographics
NPI:1073957098
Name:REGAL PHARMACY LLC
Entity Type:Organization
Organization Name:REGAL PHARMACY LLC
Other - Org Name:REGAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HETVI
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMBHATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-350-0500
Mailing Address - Street 1:684 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-3110
Mailing Address - Country:US
Mailing Address - Phone:973-350-0500
Mailing Address - Fax:973-350-5570
Practice Address - Street 1:684 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-3110
Practice Address - Country:US
Practice Address - Phone:973-350-0500
Practice Address - Fax:973-350-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-21
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS007258003336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140031OtherPK
NJ0380334Medicaid
6793760001Medicare NSC