Provider Demographics
NPI:1659444297
Name:MICRIMAR INC
Entity Type:Organization
Organization Name:MICRIMAR INC
Other - Org Name:LINCOLN DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:VIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:856-365-3400
Mailing Address - Street 1:730 BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:NARBERTH
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1402
Mailing Address - Country:US
Mailing Address - Phone:856-365-3400
Mailing Address - Fax:
Practice Address - Street 1:221 S BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1287
Practice Address - Country:US
Practice Address - Phone:856-365-3400
Practice Address - Fax:610-668-1077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00288000333600000X
3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2448408Medicaid
NJ4322908Medicaid
3107439OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NJ4322908Medicaid