Provider Demographics
NPI:1336326941
Name:GUS PHARMACY, LLC
Entity Type:Organization
Organization Name:GUS PHARMACY, LLC
Other - Org Name:KENNEDY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/RPIC
Authorized Official - Prefix:
Authorized Official - First Name:KONSTANTINOS
Authorized Official - Middle Name:
Authorized Official - Last Name:TZAFEROS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:856-346-3535
Mailing Address - Street 1:42 E LAUREL RD
Mailing Address - Street 2:SUITE 1900
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1354
Mailing Address - Country:US
Mailing Address - Phone:856-346-3535
Mailing Address - Fax:856-346-4953
Practice Address - Street 1:42 E LAUREL RD
Practice Address - Street 2:SUITE 1900
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-346-3535
Practice Address - Fax:856-346-4953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS002557003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4314808Medicaid
NJ4314808Medicaid