Provider Demographics
NPI:1376089706
Name:JRE AVE MARIA LLC
Entity Type:Organization
Organization Name:JRE AVE MARIA LLC
Other - Org Name:RANDOLPH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHALY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-442-4020
Mailing Address - Street 1:124 ROUTE 10
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-2415
Mailing Address - Country:US
Mailing Address - Phone:973-442-4020
Mailing Address - Fax:
Practice Address - Street 1:124 ROUTE 10
Practice Address - Street 2:UNIT 4
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2415
Practice Address - Country:US
Practice Address - Phone:973-442-4020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JRE AVE MARIA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-09
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy