Provider Demographics
NPI:1801492285
Name:FAIRFAX, THERESA (RPH)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:FAIRFAX
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 RT 35 N
Mailing Address - Street 2:
Mailing Address - City:SEASIDE HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600RT 35 N
Practice Address - Street 2:
Practice Address - City:SEASIDE HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08751
Practice Address - Country:US
Practice Address - Phone:793-793-2890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02788100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1497850721OtherNPI