Provider Demographics
NPI:1104862564
Name:MONTCLAIR PHARMACY RX LLC
Entity Type:Organization
Organization Name:MONTCLAIR PHARMACY RX LLC
Other - Org Name:MONTCLAIR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEMA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-304-2221
Mailing Address - Street 1:732 VALLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043
Mailing Address - Country:US
Mailing Address - Phone:973-744-2113
Mailing Address - Fax:973-744-2691
Practice Address - Street 1:732 VALLEY RD
Practice Address - Street 2:
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1521
Practice Address - Country:US
Practice Address - Phone:973-744-2113
Practice Address - Fax:973-744-2691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 332B00000X
NJ28RS000427003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2056802OtherPK
NJ4248210Medicaid
2056802OtherPK
0747720001Medicare NSC