Provider Demographics
NPI:1578619847
Name:BASTA, ASHRAF M
Entity Type:Individual
Prefix:
First Name:ASHRAF
Middle Name:M
Last Name:BASTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08882-1225
Mailing Address - Country:US
Mailing Address - Phone:732-257-0069
Mailing Address - Fax:732-257-3250
Practice Address - Street 1:54 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08882-1225
Practice Address - Country:US
Practice Address - Phone:732-257-0069
Practice Address - Fax:732-257-3250
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00531800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist