Provider Demographics
NPI:1366446833
Name:PARK PLAZA PHARMACY, INC.
Entity Type:Organization
Organization Name:PARK PLAZA PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VADYM
Authorized Official - Middle Name:
Authorized Official - Last Name:DETS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-290-9111
Mailing Address - Street 1:343 HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-9514
Mailing Address - Country:US
Mailing Address - Phone:732-290-9111
Mailing Address - Fax:732-441-3693
Practice Address - Street 1:343 HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-9514
Practice Address - Country:US
Practice Address - Phone:732-290-9111
Practice Address - Fax:732-441-3693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-12
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00383600333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RS00383600OtherPHARMACY PERMIT #
3128077OtherNABP #
NJ4373502Medicaid
NJ4373502Medicaid