Provider Demographics
NPI:1417498841
Name:CHURCH, MARK (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CHURCH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 W RED BANK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-1417
Mailing Address - Country:US
Mailing Address - Phone:856-236-5250
Mailing Address - Fax:
Practice Address - Street 1:677 CROSS KEYS RD
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-9564
Practice Address - Country:US
Practice Address - Phone:856-629-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-18
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03724000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RJ07080OtherIMMUNIZATION CERTIFICATION