Provider Demographics
NPI:1508801713
Name:200 CHESTNUT ST LLC
Entity Type:Organization
Organization Name:200 CHESTNUT ST LLC
Other - Org Name:ROSELLE PARK RITA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:908-245-1396
Mailing Address - Street 1:200 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-2263
Mailing Address - Country:US
Mailing Address - Phone:908-245-1396
Mailing Address - Fax:908-245-1616
Practice Address - Street 1:200 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ROSELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07204-2263
Practice Address - Country:US
Practice Address - Phone:908-245-1396
Practice Address - Fax:908-245-1616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS006609003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0102831Medicaid
2054615OtherPK
NJ0102831Medicaid