Provider Demographics
NPI:1417624297
Name:CENTRAL AVE PHARMACY LLC
Entity Type:Organization
Organization Name:CENTRAL AVE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:ELMOATAZBELLAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAMMAA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-572-7973
Mailing Address - Street 1:355 CENTRAL AVE # 363
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018
Mailing Address - Country:US
Mailing Address - Phone:973-666-5363
Mailing Address - Fax:
Practice Address - Street 1:355 CENTRAL AVE # 363
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018
Practice Address - Country:US
Practice Address - Phone:973-666-5363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-27
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RS00785200OtherNJ STATE BOARD OF PHARMACY