Provider Demographics
NPI:1336124593
Name:21ST AVE PHARMACY INC.
Entity Type:Organization
Organization Name:21ST AVE PHARMACY INC.
Other - Org Name:TONYS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:ORESTES
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-742-1235
Mailing Address - Street 1:357 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07501-3642
Mailing Address - Country:US
Mailing Address - Phone:973-742-1235
Mailing Address - Fax:973-742-0353
Practice Address - Street 1:357 21ST AVE
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07501-3642
Practice Address - Country:US
Practice Address - Phone:973-742-1235
Practice Address - Fax:973-742-0353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00334800183500000X
NJ28RS003348332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0107905Medicaid
NJ4344600Medicaid
NJ0107905Medicaid
NJ4344600Medicaid