Provider Demographics
NPI:1780799551
Name:KEARNY SHOP-RITE INC
Entity type:Organization
Organization Name:KEARNY SHOP-RITE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:372-521-8439
Mailing Address - Street 1:PO BOX 15169
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07192-5169
Mailing Address - Country:US
Mailing Address - Phone:201-991-3568
Mailing Address - Fax:
Practice Address - Street 1:100 PASSAIC AVE
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032-1140
Practice Address - Country:US
Practice Address - Phone:201-991-3568
Practice Address - Fax:201-991-4272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS002398003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4279603Medicaid
2054505OtherPK
NJ4279603Medicaid