Provider Demographics
NPI:1740780980
Name:ICP2 LLC
Entity type:Organization
Organization Name:ICP2 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMMOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-809-2820
Mailing Address - Street 1:661MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07503
Mailing Address - Country:US
Mailing Address - Phone:973-307-9000
Mailing Address - Fax:973-754-0044
Practice Address - Street 1:661MAIN STREET
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503
Practice Address - Country:US
Practice Address - Phone:973-307-9000
Practice Address - Fax:973-754-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-14
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007604003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176021OtherPK