Provider Demographics
NPI:1679712061
Name:FIVE CORNERS PHARMACY LLP
Entity type:Organization
Organization Name:FIVE CORNERS PHARMACY LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/ OWNERS
Authorized Official - Prefix:
Authorized Official - First Name:AMIR / HANI
Authorized Official - Middle Name:
Authorized Official - Last Name:TADROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-217-0092
Mailing Address - Street 1:591 SUMMIT AVE. STORE #1
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:591 SUMMIT AVE. STORE #1
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306
Practice Address - Country:US
Practice Address - Phone:201-217-0092
Practice Address - Fax:201-217-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS006873003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3195585OtherNCPDP PROVIDER IDENTIFICATION NUMBER