Provider Demographics
NPI:1245216597
Name:ELMORA PHARMACY, INC.
Entity Type:Organization
Organization Name:ELMORA PHARMACY, INC.
Other - Org Name:ELMORA HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:908-352-8808
Mailing Address - Street 1:162 ELMORA AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-1148
Mailing Address - Country:US
Mailing Address - Phone:908-352-8808
Mailing Address - Fax:908-352-5621
Practice Address - Street 1:162 ELMORA AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-1148
Practice Address - Country:US
Practice Address - Phone:908-352-8808
Practice Address - Fax:908-352-5621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4243803Medicaid
NJ2526301Medicaid
NJ2526301Medicaid