Provider Demographics
NPI:1952418147
Name:KLEINS BROADWAY & MAIN INC
Entity Type:Organization
Organization Name:KLEINS BROADWAY & MAIN INC
Other - Org Name:KLEIN'S SHOPRITE PHARMACY #547
Other - Org Type:Doing Business As
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:732-521-8439
Mailing Address - Street 1:223 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-3501
Mailing Address - Country:US
Mailing Address - Phone:410-630-0600
Mailing Address - Fax:410-638-6469
Practice Address - Street 1:223 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3501
Practice Address - Country:US
Practice Address - Phone:410-630-0600
Practice Address - Fax:410-638-6469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP014153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2116538OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MD528282900Medicaid
0713530001Medicare NSC