Provider Demographics
NPI:1194826198
Name:SHIRDI BABA PHARMACY CORP
Entity type:Organization
Organization Name:SHIRDI BABA PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VISWESWARA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KADIYAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-278-2207
Mailing Address - Street 1:688 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07503-2622
Mailing Address - Country:US
Mailing Address - Phone:973-278-2207
Mailing Address - Fax:973-278-1258
Practice Address - Street 1:688 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2622
Practice Address - Country:US
Practice Address - Phone:973-278-2207
Practice Address - Fax:973-278-1258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RS00484900OtherSTATE PHARMACY LICENSE
NJ6015204Medicaid
BS3855408OtherDEA NUMBER
BS3855408OtherDEA NUMBER