Provider Demographics
NPI:1750391173
Name:PROSPECT PHARMACY LLC
Entity type:Organization
Organization Name:PROSPECT PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIT IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:NASER
Authorized Official - Middle Name:M
Authorized Official - Last Name:OBEIDALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:973-389-1311
Mailing Address - Street 1:214 HALEDON AVE
Mailing Address - Street 2:
Mailing Address - City:PROSPECT PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07508-2024
Mailing Address - Country:US
Mailing Address - Phone:973-389-1311
Mailing Address - Fax:973-389-2315
Practice Address - Street 1:214 HALEDON AVE
Practice Address - Street 2:
Practice Address - City:PROSPECT PARK
Practice Address - State:NJ
Practice Address - Zip Code:07508-2024
Practice Address - Country:US
Practice Address - Phone:973-389-1311
Practice Address - Fax:973-389-2315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS006165003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3144792OtherNABP#
NJ8956405Medicaid
NJ4709670001Medicare NSC