Provider Demographics
NPI:1558593574
Name:FAIRLAWN PHARMACY LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:FAIRLAWN PHARMACY LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:BEDA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:201-773-6090
Mailing Address - Street 1:14-25 PLAZA RD
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3546
Mailing Address - Country:US
Mailing Address - Phone:201-773-6090
Mailing Address - Fax:201-773-6089
Practice Address - Street 1:14-25 PLAZA RD
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3546
Practice Address - Country:US
Practice Address - Phone:201-773-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-10
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS007001003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0230936Medicaid
NJ6398370001Medicare NSC