Provider Demographics
NPI:1295840072
Name:VILLAGE SUPER MARKET OF NJ LP
Entity Type:Organization
Organization Name:VILLAGE SUPER MARKET OF NJ LP
Other - Org Name:SHOPRITE PHARMACY OF RIO GRANDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8448
Mailing Address - Street 1:733 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-3223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 ROUTE 47 SOUTH
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:NJ
Practice Address - Zip Code:08242-1326
Practice Address - Country:US
Practice Address - Phone:609-886-0124
Practice Address - Fax:609-889-0219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRS004543333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4533607Medicaid
3132507OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3132507OtherOTHER ID NUMBER-COMMERCIAL NUMBER