Provider Demographics
NPI:1235140757
Name:MEDICAL MALL RX INC
Entity Type:Organization
Organization Name:MEDICAL MALL RX INC
Other - Org Name:MEDICAL MALL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PARTHIV
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-244-4747
Mailing Address - Street 1:9 HOSPITAL DR STE B3
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-6425
Mailing Address - Country:US
Mailing Address - Phone:732-244-4747
Mailing Address - Fax:732-244-4873
Practice Address - Street 1:9 HOSPITAL DR STE B3
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6425
Practice Address - Country:US
Practice Address - Phone:732-244-4747
Practice Address - Fax:732-244-4873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS001912003336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0482595Medicaid
2148314OtherPK
7323040001Medicare NSC