Provider Demographics
NPI:1881015717
Name:WILLOW AVE PHARMACY LLC
Entity Type:Organization
Organization Name:WILLOW AVE PHARMACY LLC
Other - Org Name:CAREPOINT HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SNEHAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-763-1961
Mailing Address - Street 1:308 WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030
Mailing Address - Country:US
Mailing Address - Phone:201-418-2830
Mailing Address - Fax:201-418-2834
Practice Address - Street 1:308 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030
Practice Address - Country:US
Practice Address - Phone:201-418-2830
Practice Address - Fax:201-418-2834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-19
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NJ28RS007304003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143572OtherPK
NJ7065750001Medicare NSC