Provider Demographics
NPI:1710261730
Name:BOYDS PHARMACY OF MEDFORD INC
Entity Type:Organization
Organization Name:BOYDS PHARMACY OF MEDFORD INC
Other - Org Name:BOYD'S PHARMACY OF MEDFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:TOOTELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-975-8197
Mailing Address - Street 1:5 WILKINS STATION RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9606
Mailing Address - Country:US
Mailing Address - Phone:609-975-8197
Mailing Address - Fax:609-975-8223
Practice Address - Street 1:5 WILKINS STATION RD STE 100
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-9606
Practice Address - Country:US
Practice Address - Phone:609-975-8197
Practice Address - Fax:609-975-8223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
NJ28RS007154003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132262OtherPK
NJ0286541Medicaid
NJ0286541Medicaid