Provider Demographics
NPI:1710036975
Name:SOWADAUTH, INC.
Entity Type:Organization
Organization Name:SOWADAUTH, INC.
Other - Org Name:ROCK RIDGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:H
Authorized Official - Last Name:KOPACKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:201-444-4190
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:191 ROCK ROAD
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-0605
Mailing Address - Country:US
Mailing Address - Phone:201-444-4190
Mailing Address - Fax:201-444-2698
Practice Address - Street 1:191 ROCK RD
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-1706
Practice Address - Country:US
Practice Address - Phone:201-444-4190
Practice Address - Fax:201-444-2698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4873333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6239609Medicaid
NJ6239609Medicaid