Provider Demographics
NPI:1841301801
Name:AMETHYST PHARMACY
Entity type:Organization
Organization Name:AMETHYST PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-222-5222
Mailing Address - Street 1:550 NEWARK AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-1326
Mailing Address - Country:US
Mailing Address - Phone:201-222-5222
Mailing Address - Fax:201-792-7911
Practice Address - Street 1:550 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1326
Practice Address - Country:US
Practice Address - Phone:201-222-5222
Practice Address - Fax:201-792-7911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00481800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5613507Medicaid
NJ3134741OtherNABP #
NJ5613507Medicaid