Provider Demographics
NPI:1740207679
Name:ESSGEE PHILLIPSBURG CORP
Entity Type:Organization
Organization Name:ESSGEE PHILLIPSBURG CORP
Other - Org Name:PHILLIPSBURG PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SREEDHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VAJINEPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-528-1008
Mailing Address - Street 1:96 BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-1836
Mailing Address - Country:US
Mailing Address - Phone:908-454-4352
Mailing Address - Fax:908-454-4377
Practice Address - Street 1:96 BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1836
Practice Address - Country:US
Practice Address - Phone:908-454-4352
Practice Address - Fax:908-454-4377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS006759003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0321711Medicaid
NJ3103520OtherNCPDP
NJ0321711Medicaid