Provider Demographics
NPI:1689922569
Name:PALMYRA PHARMACY LLC
Entity Type:Organization
Organization Name:PALMYRA PHARMACY LLC
Other - Org Name:PALMYRA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JITENKUMAR
Authorized Official - Middle Name:P
Authorized Official - Last Name:NATHANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-786-1615
Mailing Address - Street 1:1 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NJ
Mailing Address - Zip Code:08065-1604
Mailing Address - Country:US
Mailing Address - Phone:856-786-1615
Mailing Address - Fax:856-786-2317
Practice Address - Street 1:1 E BROAD ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:NJ
Practice Address - Zip Code:08065-1604
Practice Address - Country:US
Practice Address - Phone:856-786-1615
Practice Address - Fax:856-786-2317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007207003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0316229Medicaid
2136832OtherPK