Provider Demographics
NPI:1851740401
Name:FANWOOD RX CORP
Entity Type:Organization
Organization Name:FANWOOD RX CORP
Other - Org Name:FANWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:MITUL
Authorized Official - Middle Name:P
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:908-680-6936
Mailing Address - Street 1:1 TED LIGHT WAY
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854
Mailing Address - Country:US
Mailing Address - Phone:848-228-9655
Mailing Address - Fax:908-680-6937
Practice Address - Street 1:246 SOUTH AVE STE 104
Practice Address - Street 2:
Practice Address - City:FANWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07023-1253
Practice Address - Country:US
Practice Address - Phone:908-680-6936
Practice Address - Fax:908-680-6937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-05
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X, 3336S0011X
NJ28RS007495003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0547891Medicaid
2160637OtherPK