Provider Demographics
NPI:1831413509
Name:BLACK, REGINA MICHELLE (RPH)
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:MICHELLE
Last Name:BLACK
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 1:180 PASSAIC AVE
Mailing Address - Street 2:UNIT B-5
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-3516
Mailing Address - Country:US
Mailing Address - Phone:800-447-4791
Mailing Address - Fax:800-266-1644
Practice Address - Street 1:180 PASSAIC AVE
Practice Address - Street 2:UNIT B-5
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-3516
Practice Address - Country:US
Practice Address - Phone:800-447-4791
Practice Address - Fax:800-266-1644
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02214600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist