Provider Demographics
NPI:1154521664
Name:UNION LAKE SUPERMARKET LLC
Entity type:Organization
Organization Name:UNION LAKE SUPERMARKET LLC
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:732-521-8439
Mailing Address - Street 1:2130 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-1304
Mailing Address - Country:US
Mailing Address - Phone:856-327-9950
Mailing Address - Fax:856-776-2313
Practice Address - Street 1:2130 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-1304
Practice Address - Country:US
Practice Address - Phone:856-327-9950
Practice Address - Fax:856-776-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0208965Medicaid
NJ0208965Medicaid