Provider Demographics
NPI:1629144720
Name:PRINCETON HEALTHCARE SYSTEM A NEW JERSEY NON-PROFIT CORP
Entity Type:Organization
Organization Name:PRINCETON HEALTHCARE SYSTEM A NEW JERSEY NON-PROFIT CORP
Other - Org Name:PENN MEDICINE PRINCETON HEALTH OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMETRIADES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:609-853-6113
Mailing Address - Street 1:1 PLAINSBORO RD
Mailing Address - Street 2:
Mailing Address - City:PLAINSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08536-1913
Mailing Address - Country:US
Mailing Address - Phone:609-853-6130
Mailing Address - Fax:609-853-6128
Practice Address - Street 1:1 PLAINSBORO RD
Practice Address - Street 2:
Practice Address - City:PLAINSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08536-1913
Practice Address - Country:US
Practice Address - Phone:609-853-6130
Practice Address - Fax:609-853-6128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BP3500X, 333600000X, 3336H0001X, 3336M0003X
NJ28RS004268003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2055085OtherPK
NJ6471404Medicaid
NJ0896750001Medicare NSC