Provider Demographics
NPI:1972038446
Name:ST MARIA PHARMACY
Entity Type:Organization
Organization Name:ST MARIA PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:RANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WISA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:732-485-9570
Mailing Address - Street 1:1004 COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-5217
Mailing Address - Country:US
Mailing Address - Phone:732-485-9570
Mailing Address - Fax:
Practice Address - Street 1:1004 COMMONS DR
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-5217
Practice Address - Country:US
Practice Address - Phone:732-485-9570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03792000302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization