Provider Demographics
NPI:1346655990
Name:EFRAIMOVICH, ILIA
Entity Type:Individual
Prefix:
First Name:ILIA
Middle Name:
Last Name:EFRAIMOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 MULE RD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-5029
Mailing Address - Country:US
Mailing Address - Phone:732-914-1470
Mailing Address - Fax:
Practice Address - Street 1:31 MULE RD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-5029
Practice Address - Country:US
Practice Address - Phone:732-914-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03150000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist