Provider Demographics
NPI:1528428828
Name:SAINT MINA & SAINT MOSES PHARMACY
Entity type:Organization
Organization Name:SAINT MINA & SAINT MOSES PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:NADY
Authorized Official - Middle Name:
Authorized Official - Last Name:AZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-455-4785
Mailing Address - Street 1:779 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3943
Mailing Address - Country:US
Mailing Address - Phone:201-455-8600
Mailing Address - Fax:201-455-8665
Practice Address - Street 1:779 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3943
Practice Address - Country:US
Practice Address - Phone:201-455-8600
Practice Address - Fax:201-455-8665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X
NJ28RS007472003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158617OtherPK