Provider Demographics
NPI:1578542858
Name:SHRI GANESHJI PHARMACY, INC.
Entity Type:Organization
Organization Name:SHRI GANESHJI PHARMACY, INC.
Other - Org Name:BERGENLINE DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RP IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:ALMANZA
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:201-867-0615
Mailing Address - Street 1:5005 BERGLINE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-5563
Mailing Address - Country:US
Mailing Address - Phone:201-867-0615
Mailing Address - Fax:
Practice Address - Street 1:5005 BERGLINE AVE
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-5563
Practice Address - Country:US
Practice Address - Phone:201-867-0615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00577200333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8060100Medicaid
NJ3892100001Medicare ID - Type UnspecifiedCMS MEDICARE