Provider Demographics
NPI:1619084506
Name:FORGANG, MARK ALLEN (RP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:FORGANG
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3317 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-4554
Mailing Address - Country:US
Mailing Address - Phone:732-775-3600
Mailing Address - Fax:
Practice Address - Street 1:3317 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-4554
Practice Address - Country:US
Practice Address - Phone:732-775-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00371900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4367502Medicaid
NJ4367502Medicaid