Provider Demographics
NPI:1720593510
Name:GERGES, MARIO H (RPH)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:H
Last Name:GERGES
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8422 13TH AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-3339
Mailing Address - Country:US
Mailing Address - Phone:631-526-3629
Mailing Address - Fax:
Practice Address - Street 1:PASSAIC COMMUNITY PHARMACY
Practice Address - Street 2:339 PASSAIC ST
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-5818
Practice Address - Country:US
Practice Address - Phone:973-471-0160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03898500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty