Provider Demographics
NPI:1154464170
Name:VILLAGE SUPER MARKET OF NJ LP
Entity Type:Organization
Organization Name:VILLAGE SUPER MARKET OF NJ LP
Other - Org Name:SHOPRITE PHARMACY OF WASHINGTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8439
Mailing Address - Street 1:733 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-3223
Mailing Address - Country:US
Mailing Address - Phone:908-835-0781
Mailing Address - Fax:908-835-0942
Practice Address - Street 1:300 ROUTE 31 SOUTH
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882
Practice Address - Country:US
Practice Address - Phone:908-835-0781
Practice Address - Fax:908-835-0942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRS0038243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3128154OtherNCPDP
NJ4374908Medicaid
NJ1309060018Medicare NSC