Provider Demographics
NPI:1598009383
Name:MEDICINE MAN RX LLC
Entity Type:Organization
Organization Name:MEDICINE MAN RX LLC
Other - Org Name:MEDICINE MAN PHARMACY & COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PANKIT
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-942-9777
Mailing Address - Street 1:511 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-4993
Mailing Address - Country:US
Mailing Address - Phone:201-942-9777
Mailing Address - Fax:201-942-9779
Practice Address - Street 1:511 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-4993
Practice Address - Country:US
Practice Address - Phone:201-942-9777
Practice Address - Fax:201-942-9779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007229003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0383911Medicaid
2153660OtherPK