Provider Demographics
NPI:1578050357
Name:HEALTH SMART PHARMACY & CONVENIENCE STORE LLC
Entity Type:Organization
Organization Name:HEALTH SMART PHARMACY & CONVENIENCE STORE LLC
Other - Org Name:HEALTH SMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VEA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAYABA-WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-993-3325
Mailing Address - Street 1:2709 JOHN F KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-5763
Mailing Address - Country:US
Mailing Address - Phone:201-360-3784
Mailing Address - Fax:201-360-3747
Practice Address - Street 1:2709 JOHN F KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-5763
Practice Address - Country:US
Practice Address - Phone:201-360-3784
Practice Address - Fax:201-360-3747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-18
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007626003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177414OtherPK