Provider Demographics
NPI:1407907660
Name:RED BANK PHARMACY
Entity Type:Organization
Organization Name:RED BANK PHARMACY
Other - Org Name:PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-741-5288
Mailing Address - Street 1:134 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1927
Mailing Address - Country:US
Mailing Address - Phone:732-741-5288
Mailing Address - Fax:732-741-2274
Practice Address - Street 1:134 BROAD ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1927
Practice Address - Country:US
Practice Address - Phone:732-741-5288
Practice Address - Fax:732-741-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS001462003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4273605Medicaid
NJ4273605Medicaid