Provider Demographics
NPI:1447767595
Name:ALEXANDRIA PHARMACY LLC
Entity Type:Organization
Organization Name:ALEXANDRIA PHARMACY LLC
Other - Org Name:ALEXANDRIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSSAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-469-9653
Mailing Address - Street 1:327 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-3704
Mailing Address - Country:US
Mailing Address - Phone:908-469-9653
Mailing Address - Fax:908-469-9655
Practice Address - Street 1:327 N BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3704
Practice Address - Country:US
Practice Address - Phone:908-469-9653
Practice Address - Fax:908-469-9655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007598003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175483OtherPK
NJ0604798Medicaid