Provider Demographics
NPI:1548249717
Name:TERRACE APOTHECARY INC
Entity type:Organization
Organization Name:TERRACE APOTHECARY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WESTLEY
Authorized Official - Middle Name:V
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:III
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:201-384-7171
Mailing Address - Street 1:169 TERRACE ST
Mailing Address - Street 2:
Mailing Address - City:HAWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07641-1835
Mailing Address - Country:US
Mailing Address - Phone:201-384-7171
Mailing Address - Fax:201-384-4433
Practice Address - Street 1:169 TERRACE ST
Practice Address - Street 2:
Practice Address - City:HAWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07641-1835
Practice Address - Country:US
Practice Address - Phone:201-384-7171
Practice Address - Fax:201-384-4433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-16
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS004785003336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3134210OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NJ5406307Medicaid
3134210OtherNCPDP PROVIDER IDENTIFICATION NUMBER