Provider Demographics
NPI:1790228914
Name:AVICHAL, PRITY S
Entity Type:Individual
Prefix:
First Name:PRITY
Middle Name:S
Last Name:AVICHAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 PLANE ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-3820
Mailing Address - Country:US
Mailing Address - Phone:908-456-2843
Mailing Address - Fax:
Practice Address - Street 1:327 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-9426
Practice Address - Country:US
Practice Address - Phone:908-686-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-19
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03828600183500000X
NJ28RJ06938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6892701Medicaid