Provider Demographics
NPI:1295846665
Name:VAN HOUTEN PHARMACY INC.
Entity Type:Organization
Organization Name:VAN HOUTEN PHARMACY INC.
Other - Org Name:VAN HOUTEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:VOINOV
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:973-779-1122
Mailing Address - Street 1:669 VAN HOUTEN AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-2125
Mailing Address - Country:US
Mailing Address - Phone:973-779-1122
Mailing Address - Fax:973-779-8996
Practice Address - Street 1:669 VAN HOUTEN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2125
Practice Address - Country:US
Practice Address - Phone:973-779-1122
Practice Address - Fax:973-779-8996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS004691003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5156009Medicaid
3133458OtherNABP #
NJ5156009Medicaid