Provider Demographics
NPI:1568551257
Name:HACKENSACK UNIVERSITY MEDICAL CENTER
Entity Type:Organization
Organization Name:HACKENSACK UNIVERSITY MEDICAL CENTER
Other - Org Name:HACKENSACK UNIVERSITY MEDICAL CENTER PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONSULTANT/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LUPANO
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:551-996-4092
Mailing Address - Street 1:20 PROSPECT AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1997
Mailing Address - Country:US
Mailing Address - Phone:551-996-8744
Mailing Address - Fax:551-996-8757
Practice Address - Street 1:20 PROSPECT AVE
Practice Address - Street 2:STE 102
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1997
Practice Address - Country:US
Practice Address - Phone:551-996-8744
Practice Address - Fax:551-996-8757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
NJ28RS006456003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0071960Medicaid
2055528OtherPK
NJ0071960Medicaid