Provider Demographics
NPI:1861867038
Name:MADURA RX LLC
Entity Type:Organization
Organization Name:MADURA RX LLC
Other - Org Name:MADURA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TRUPTI
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-674-2748
Mailing Address - Street 1:115 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-1648
Mailing Address - Country:US
Mailing Address - Phone:732-721-1732
Mailing Address - Fax:732-553-7252
Practice Address - Street 1:115 N BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08879-1648
Practice Address - Country:US
Practice Address - Phone:732-721-1732
Practice Address - Fax:732-553-7252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-14
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00116700333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155951OtherPK
NJ0522058Medicaid
2155951OtherPK