Provider Demographics
NPI:1700807773
Name:UNION AVENUE HEALTHCARE INC
Entity Type:Organization
Organization Name:UNION AVENUE HEALTHCARE INC
Other - Org Name:UNION AVENUE LEGEND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JATIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-356-3113
Mailing Address - Street 1:433 W UNION AVE
Mailing Address - Street 2:
Mailing Address - City:BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08805-1220
Mailing Address - Country:US
Mailing Address - Phone:732-356-3113
Mailing Address - Fax:732-356-6691
Practice Address - Street 1:433 W UNION AVE
Practice Address - Street 2:
Practice Address - City:BOUND BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08805-1220
Practice Address - Country:US
Practice Address - Phone:732-356-3113
Practice Address - Fax:732-356-6691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS005842003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2054957OtherPK
NJ8385301Medicaid
4046090001Medicare NSC