Provider Demographics
NPI:1407392343
Name:FRESH EMPORIUM FOOD MARKET, CORP
Entity Type:Organization
Organization Name:FRESH EMPORIUM FOOD MARKET, CORP
Other - Org Name:FRESH IMPERIUM PHARMACY JEFFERSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-324-4924
Mailing Address - Street 1:757 STATE ROUTE 15 S
Mailing Address - Street 2:
Mailing Address - City:LAKE HOPATCONG
Mailing Address - State:NJ
Mailing Address - Zip Code:07849-2284
Mailing Address - Country:US
Mailing Address - Phone:862-803-9027
Mailing Address - Fax:
Practice Address - Street 1:757 STATE ROUTE 15 S
Practice Address - Street 2:
Practice Address - City:LAKE HOPATCONG
Practice Address - State:NJ
Practice Address - Zip Code:07849-2284
Practice Address - Country:US
Practice Address - Phone:862-803-9027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00753600333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167102OtherPK