Provider Demographics
NPI:1114399649
Name:DURHAM PHARMACY LLC
Entity Type:Organization
Organization Name:DURHAM PHARMACY LLC
Other - Org Name:DURHAM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSWAMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-548-8224
Mailing Address - Street 1:124 DURHAM AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-2528
Mailing Address - Country:US
Mailing Address - Phone:908-548-8224
Mailing Address - Fax:908-205-0060
Practice Address - Street 1:124 DURHAM AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-2528
Practice Address - Country:US
Practice Address - Phone:908-548-8224
Practice Address - Fax:908-205-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-23
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007449003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153149OtherPK