Provider Demographics
NPI:1740226836
Name:THE ESTAUGH
Entity Type:Organization
Organization Name:THE ESTAUGH
Other - Org Name:MEDFORD LEAS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY DIR
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:609-654-3391
Mailing Address - Street 1:1 MEDFORD LEAS
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-2254
Mailing Address - Country:US
Mailing Address - Phone:609-654-3269
Mailing Address - Fax:609-257-0827
Practice Address - Street 1:1 MEDFORD LEAS
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-2254
Practice Address - Country:US
Practice Address - Phone:609-654-3269
Practice Address - Fax:609-257-0827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336M0003X
NJ28RS001920003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2056046OtherPK
NJ4303504Medicaid