Provider Demographics
NPI:1194830976
Name:INSERRA SUPERMARKETS INC
Entity Type:Organization
Organization Name:INSERRA SUPERMARKETS INC
Other - Org Name:SHOPRITE PHARMACY
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:PO BOX 781250
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-1250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 PATERSON AVE
Practice Address - Street 2:
Practice Address - City:WALLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07057-2101
Practice Address - Country:US
Practice Address - Phone:973-471-7575
Practice Address - Fax:973-471-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRS004991333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0252395Medicaid
NJ0252689OtherMEDICAID DME
3135894OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3135894OtherOTHER ID NUMBER-COMMERCIAL NUMBER