Provider Demographics
NPI:1740285071
Name:15W PHARMACY INC
Entity type:Organization
Organization Name:15W PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REIMBURSEMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-346-1333
Mailing Address - Street 1:95 NEWFIELD AVE
Mailing Address - Street 2:STE B
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-3824
Mailing Address - Country:US
Mailing Address - Phone:732-346-1333
Mailing Address - Fax:732-346-9221
Practice Address - Street 1:95 NEWFIELD AVE
Practice Address - Street 2:STE B
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-3824
Practice Address - Country:US
Practice Address - Phone:732-346-1333
Practice Address - Fax:732-346-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS006070003336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019646380001Medicaid
NY02282268Medicaid
NJ3144209OtherNCPDP
NJ8710317Medicaid
NJ8710309Medicaid
PA0019646380001Medicaid