Provider Demographics
NPI:1558303172
Name:HADDON PHARMACY INC
Entity Type:Organization
Organization Name:HADDON PHARMACY INC
Other - Org Name:HADDON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-854-5655
Mailing Address - Street 1:330 HADDON AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-1241
Mailing Address - Country:US
Mailing Address - Phone:856-854-5655
Mailing Address - Fax:856-854-5059
Practice Address - Street 1:330 HADDON AVE
Practice Address - Street 2:
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08108-1241
Practice Address - Country:US
Practice Address - Phone:856-854-5655
Practice Address - Fax:856-854-5059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS003652003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2058050OtherPK
NJ4363001Medicaid
NJ4363001Medicaid
3126910OtherOTHER ID NUMBER-COMMERCIAL NUMBER