Provider Demographics
NPI:1184796864
Name:POETS SQUARE PHARMACY INC
Entity type:Organization
Organization Name:POETS SQUARE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KOMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BAJWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-409-1100
Mailing Address - Street 1:10 THOREAU DR
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-4666
Mailing Address - Country:US
Mailing Address - Phone:732-409-1100
Mailing Address - Fax:732-409-3440
Practice Address - Street 1:10 THOREAU DR
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-4666
Practice Address - Country:US
Practice Address - Phone:732-409-1100
Practice Address - Fax:732-409-3440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS005754003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8254303Medicaid
NJ8254303Medicaid
NJ0807380001Medicare NSC