Provider Demographics
NPI:1861507634
Name:VILLAGE SUPER MARKET OF NJ LP
Entity type:Organization
Organization Name:VILLAGE SUPER MARKET OF NJ LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8448
Mailing Address - Street 1:1158 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:STIRLING
Mailing Address - State:NJ
Mailing Address - Zip Code:07980-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1158 VALLEY RD
Practice Address - Street 2:
Practice Address - City:STIRLING
Practice Address - State:NJ
Practice Address - Zip Code:07980-1500
Practice Address - Country:US
Practice Address - Phone:908-647-1903
Practice Address - Fax:908-626-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
NJRS000977333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4285506Medicaid
3115424OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3115424OtherOTHER ID NUMBER-COMMERCIAL NUMBER