Provider Demographics
NPI:1760597546
Name:SHOPRITE OF LINCOLN PARK INC
Entity Type:Organization
Organization Name:SHOPRITE OF LINCOLN PARK INC
Other - Org Name:SHOPRITE PHARMACY 297
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8439
Mailing Address - Street 1:60 BEAVERBROOK RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1771
Mailing Address - Country:US
Mailing Address - Phone:973-694-7141
Mailing Address - Fax:973-694-1528
Practice Address - Street 1:60 BEAVERBROOK RD
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1771
Practice Address - Country:US
Practice Address - Phone:973-694-7141
Practice Address - Fax:973-694-1528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS006254003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2058375OtherPK
NJ4388402Medicaid
0730670001Medicare NSC