Provider Demographics
NPI:1083752216
Name:MYSTIC PHARMACY INC
Entity type:Organization
Organization Name:MYSTIC PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:609-296-0934
Mailing Address - Street 1:972 RADIO RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE EGG HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08087
Mailing Address - Country:US
Mailing Address - Phone:609-296-0934
Mailing Address - Fax:609-296-6250
Practice Address - Street 1:972 RADIO RD
Practice Address - Street 2:
Practice Address - City:LITTLE EGG HARBOR
Practice Address - State:NJ
Practice Address - Zip Code:08087
Practice Address - Country:US
Practice Address - Phone:609-296-0934
Practice Address - Fax:609-296-6250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00391800333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4337905Medicaid
NJ1271970001Medicare ID - Type Unspecified