Provider Demographics
NPI:1558303339
Name:MCDERMOTT DRUG CORP
Entity Type:Organization
Organization Name:MCDERMOTT DRUG CORP
Other - Org Name:MCDERMOTT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMIT
Authorized Official - Middle Name:
Authorized Official - Last Name:DATWANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-790-8486
Mailing Address - Street 1:433 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07502-1917
Mailing Address - Country:US
Mailing Address - Phone:973-790-8486
Mailing Address - Fax:973-790-3315
Practice Address - Street 1:433 UNION AVE
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07502-1917
Practice Address - Country:US
Practice Address - Phone:973-790-8486
Practice Address - Fax:973-790-3315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS006270003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0016233Medicaid
2058221OtherPK
3127619OtherNCPDP PROVIDER IDENTIFICATION NUMBER