Provider Demographics
NPI:1407961287
Name:SHOPRITE PHARMACY 108
Entity Type:Organization
Organization Name:SHOPRITE PHARMACY 108
Other - Org Name:SHOPRITE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:GADKARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8448
Mailing Address - Street 1:355 DAVIDSONS MILL RD
Mailing Address - Street 2:
Mailing Address - City:JAMESBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-3014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:985 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1501
Practice Address - Country:US
Practice Address - Phone:718-982-8615
Practice Address - Fax:718-982-8633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022227333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01521631Medicaid
3355181OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY01521631Medicaid