Provider Demographics
NPI:1760803019
Name:TRISTATE WELLNESS PHARMACY
Entity Type:Organization
Organization Name:TRISTATE WELLNESS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BASSEM
Authorized Official - Middle Name:
Authorized Official - Last Name:GIRGIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-421-3738
Mailing Address - Street 1:51 BRUNSWICK WOODS DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:290 DUNHAMS CORNER ROAD
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816
Practice Address - Country:US
Practice Address - Phone:908-421-3738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-03
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy