Provider Demographics
NPI:1649633686
Name:TRI-STATE PHARMACEUTICAL LLC
Entity type:Organization
Organization Name:TRI-STATE PHARMACEUTICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-475-0761
Mailing Address - Street 1:317 BRICK BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6031
Mailing Address - Country:US
Mailing Address - Phone:888-475-0761
Mailing Address - Fax:848-228-2239
Practice Address - Street 1:317 BRICK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6031
Practice Address - Country:US
Practice Address - Phone:888-475-0761
Practice Address - Fax:848-228-2239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS007354003336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159478OtherPK
NJ0547174Medicaid
NJ0547174Medicaid