Provider Demographics
NPI:1285722702
Name:BETHEL
Entity type:Organization
Organization Name:BETHEL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-477-3057
Mailing Address - Street 1:185 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-3332
Mailing Address - Country:US
Mailing Address - Phone:973-675-2951
Mailing Address - Fax:973-678-0339
Practice Address - Street 1:185 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-3332
Practice Address - Country:US
Practice Address - Phone:973-675-2951
Practice Address - Fax:973-678-0339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS004080003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157734OtherPK
3123762OtherNCPDP
NJ4390504Medicaid