Provider Demographics
NPI:1164828802
Name:RYLA COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:RYLA COMMUNITY PHARMACY
Other - Org Name:RYLA COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:BUSHRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOFAHREDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-313-7681
Mailing Address - Street 1:4301 MAPLE AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-1818
Mailing Address - Country:US
Mailing Address - Phone:856-320-2609
Mailing Address - Fax:856-320-2716
Practice Address - Street 1:4301 MAPLE AVE UNIT A
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-1818
Practice Address - Country:US
Practice Address - Phone:856-320-2609
Practice Address - Fax:856-320-2716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-07
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007363003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148500OtherPK
NJ7317020001Medicare NSC