Provider Demographics
NPI:1669917613
Name:LEGENDARY CARE CONSULTING
Entity type:Organization
Organization Name:LEGENDARY CARE CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANKUR
Authorized Official - Middle Name:
Authorized Official - Last Name:JETLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:973-568-7830
Mailing Address - Street 1:19 AMELIA ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-4155
Mailing Address - Country:US
Mailing Address - Phone:973-568-7830
Mailing Address - Fax:
Practice Address - Street 1:19 AMELIA ST
Practice Address - Street 2:
Practice Address - City:NORTH CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-4155
Practice Address - Country:US
Practice Address - Phone:973-568-7830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI029019001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1043592926OtherINDIVIDUAL NPI NUMBER