Provider Demographics
NPI:1366505984
Name:MIDTOWN PHARMACY
Entity Type:Organization
Organization Name:MIDTOWN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALHOUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-339-3060
Mailing Address - Street 1:812 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-2809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:812 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-2809
Practice Address - Country:US
Practice Address - Phone:201-339-3060
Practice Address - Fax:201-339-7177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS000868003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3106665OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NJ4290801Medicaid
1322860001Medicare ID - Type Unspecified