Provider Demographics
NPI:1730489956
Name:MJJ PHARMACY INC
Entity Type:Organization
Organization Name:MJJ PHARMACY INC
Other - Org Name:EXPRESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-660-9380
Mailing Address - Street 1:25310 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-2152
Mailing Address - Country:US
Mailing Address - Phone:718-413-7077
Mailing Address - Fax:718-413-4757
Practice Address - Street 1:25310 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-2152
Practice Address - Country:US
Practice Address - Phone:718-413-7077
Practice Address - Fax:718-413-4757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0304203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03292748Medicaid
5801306OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5801306OtherNCPDP PROVIDER IDENTIFICATION NUMBER