Provider Demographics
NPI:1669589867
Name:KLEINS AT RIVERSIDE INC
Entity type:Organization
Organization Name:KLEINS AT RIVERSIDE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8439
Mailing Address - Street 1:1321 RIVERSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:BELCAMP
Mailing Address - State:MD
Mailing Address - Zip Code:21017-1388
Mailing Address - Country:US
Mailing Address - Phone:410-757-6601
Mailing Address - Fax:410-297-2276
Practice Address - Street 1:1321 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:BELCAMP
Practice Address - State:MD
Practice Address - Zip Code:21017-1388
Practice Address - Country:US
Practice Address - Phone:410-757-6601
Practice Address - Fax:410-297-2276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP017193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD190692500Medicaid
2118594OtherNCPDP PROVIDER IDENTIFICATION NUMBER
2118594OtherNCPDP PROVIDER IDENTIFICATION NUMBER