Provider Demographics
NPI:1225130354
Name:FOURTH AVE PHARMACY LLC
Entity Type:Organization
Organization Name:FOURTH AVE PHARMACY LLC
Other - Org Name:FOURTH AVENUE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:AYUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:GAJERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-483-3872
Mailing Address - Street 1:329 ROSEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-1757
Mailing Address - Country:US
Mailing Address - Phone:973-483-3872
Mailing Address - Fax:973-483-6956
Practice Address - Street 1:329 ROSEVILLE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1757
Practice Address - Country:US
Practice Address - Phone:973-483-3872
Practice Address - Fax:973-483-6956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
NJ28RS003352003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132840OtherPK
6653650001Medicare NSC