Provider Demographics
NPI:1245245869
Name:SAINT MARY AND JESSIE LLC
Entity Type:Organization
Organization Name:SAINT MARY AND JESSIE LLC
Other - Org Name:ADVANCED PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHRAF
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-324-4490
Mailing Address - Street 1:288 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-4042
Mailing Address - Country:US
Mailing Address - Phone:732-324-4490
Mailing Address - Fax:732-324-4491
Practice Address - Street 1:288 SMITH ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-4042
Practice Address - Country:US
Practice Address - Phone:732-324-4490
Practice Address - Fax:732-324-4491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
NJ28RS006455003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2055524OtherPK
NJ0061999Medicaid
2055524OtherPK