Provider Demographics
NPI:1952704165
Name:FAIRVIEW PHARMACY LLC
Entity Type:Organization
Organization Name:FAIRVIEW PHARMACY LLC
Other - Org Name:FAIRVIEW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTFORT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:201-840-8049
Mailing Address - Street 1:151 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NJ
Mailing Address - Zip Code:07022-1754
Mailing Address - Country:US
Mailing Address - Phone:201-840-8049
Mailing Address - Fax:201-945-0816
Practice Address - Street 1:151 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:NJ
Practice Address - Zip Code:07022-1754
Practice Address - Country:US
Practice Address - Phone:201-840-8049
Practice Address - Fax:201-945-0816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007361003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148289OtherPK