Provider Demographics
NPI:1790823706
Name:INSERRA SUPERMARKETS INC.
Entity Type:Organization
Organization Name:INSERRA SUPERMARKETS INC.
Other - Org Name:SHOPRITE PHARMACY OF LODI
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:PO BOX 8500-51250
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:973-365-2289
Mailing Address - Fax:973-365-0925
Practice Address - Street 1:175 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644
Practice Address - Country:US
Practice Address - Phone:973-365-2289
Practice Address - Fax:973-365-0925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRS003702333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3127241OtherNCPDP
NJ4366310OtherMEDICAID DME
NJ4366301Medicaid
NJ4366301Medicaid