Provider Demographics
NPI:1275669103
Name:SHREE KOTYARK INC
Entity Type:Organization
Organization Name:SHREE KOTYARK INC
Other - Org Name:PAVONIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ATUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MS RPH
Authorized Official - Phone:201-216-9666
Mailing Address - Street 1:600 PAVONIA AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-2929
Mailing Address - Country:US
Mailing Address - Phone:201-216-9666
Mailing Address - Fax:201-216-9283
Practice Address - Street 1:600 PAVONIA AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-2929
Practice Address - Country:US
Practice Address - Phone:201-216-9666
Practice Address - Fax:201-216-9283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6479201Medicaid
NJ6479201Medicaid