Provider Demographics
NPI:1811416399
Name:PASSAIC COMMUNITY PHARMACY INC
Entity Type:Organization
Organization Name:PASSAIC COMMUNITY PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AWAD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM-D
Authorized Official - Phone:973-471-0160
Mailing Address - Street 1:339 PASSAIC ST
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-5818
Mailing Address - Country:US
Mailing Address - Phone:973-471-0160
Mailing Address - Fax:973-471-0110
Practice Address - Street 1:339 PASSAIC ST
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-5818
Practice Address - Country:US
Practice Address - Phone:973-471-0160
Practice Address - Fax:973-471-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00592100332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8428310Medicaid