Provider Demographics
NPI:1811002694
Name:INSERRA SUPERMARKET INCORPORATED
Entity Type:Organization
Organization Name:INSERRA SUPERMARKET INCORPORATED
Other - Org Name:
Other - Org Type:
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:
Mailing Address - Fax:
Practice Address - Street 1:23 MARSHALL HILL RD
Practice Address - Street 2:
Practice Address - City:WEST MILFORD
Practice Address - State:NJ
Practice Address - Zip Code:07480-2144
Practice Address - Country:US
Practice Address - Phone:973-728-4754
Practice Address - Fax:973-728-4759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRS005613333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7721200Medicaid
3140112OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NJ7721218OtherMEDICAID DME
3140112OtherOTHER ID NUMBER-COMMERCIAL NUMBER