Provider Demographics
NPI:1669902102
Name:MODERN RX LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:MODERN RX LIMITED LIABILITY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KLARA
Authorized Official - Middle Name:
Authorized Official - Last Name:REIZIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-420-9000
Mailing Address - Street 1:56 CHAMBERSBRIDGE ROAD SUITE 8
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723
Mailing Address - Country:US
Mailing Address - Phone:732-475-7593
Mailing Address - Fax:732-903-7402
Practice Address - Street 1:56 CHAMBERS BRIDGE RD STE 8
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-4148
Practice Address - Country:US
Practice Address - Phone:732-475-7593
Practice Address - Fax:732-903-7402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007567003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2169830OtherPK