Provider Demographics
NPI:1902492150
Name:CARBALLEIRA, JULIENNE MARIE
Entity Type:Individual
Prefix:
First Name:JULIENNE
Middle Name:MARIE
Last Name:CARBALLEIRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 US HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-4100
Mailing Address - Country:US
Mailing Address - Phone:908-454-7553
Mailing Address - Fax:
Practice Address - Street 1:1207 US HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-4100
Practice Address - Country:US
Practice Address - Phone:908-454-7553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01960400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7307802Medicaid