Provider Demographics
NPI:1952721847
Name:ST PETER PHARMACY
Entity Type:Organization
Organization Name:ST PETER PHARMACY
Other - Org Name:ST PETER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-240-9311
Mailing Address - Street 1:15-17 ROPES PL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-4803
Mailing Address - Country:US
Mailing Address - Phone:862-240-9311
Mailing Address - Fax:862-240-9310
Practice Address - Street 1:15-17 ROPES PL
Practice Address - Street 2:#106
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-4803
Practice Address - Country:US
Practice Address - Phone:862-240-9311
Practice Address - Fax:862-240-9310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-18
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS007328003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145373OtherPK
7192150001Medicare NSC