Provider Demographics
NPI:1861643561
Name:SOUTH ORANGE PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTH ORANGE PHARMACY LLC
Other - Org Name:SOUTH ORANGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-821-5414
Mailing Address - Street 1:73 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1715
Mailing Address - Country:US
Mailing Address - Phone:973-821-5414
Mailing Address - Fax:973-275-5220
Practice Address - Street 1:73 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-1715
Practice Address - Country:US
Practice Address - Phone:973-821-5414
Practice Address - Fax:973-275-5220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NJ28RS006870003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117729OtherPK
NJ0193381Medicaid
NJ6227070001Medicaid
NJ6227070001Medicaid