Provider Demographics
NPI:1467652057
Name:JERUSALEM PHARMACY
Entity Type:Organization
Organization Name:JERUSALEM PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:YOUNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RASHEED
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:210-410-0002
Mailing Address - Street 1:1414 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2157
Mailing Address - Country:US
Mailing Address - Phone:973-340-6200
Mailing Address - Fax:973-340-6204
Practice Address - Street 1:1414 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2157
Practice Address - Country:US
Practice Address - Phone:973-340-6200
Practice Address - Fax:973-340-6204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS006707003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0156647Medicaid
NJ5969650001Medicare NSC