Provider Demographics
NPI:1285799619
Name:BRADLEY BEACH PAHRAMCY INC.
Entity type:Organization
Organization Name:BRADLEY BEACH PAHRAMCY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YATMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-774-7174
Mailing Address - Street 1:128 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRADLEY BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:07720-1030
Mailing Address - Country:US
Mailing Address - Phone:732-774-7174
Mailing Address - Fax:732-774-7175
Practice Address - Street 1:128 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRADLEY BEACH
Practice Address - State:NJ
Practice Address - Zip Code:07720-1030
Practice Address - Country:US
Practice Address - Phone:732-774-7174
Practice Address - Fax:732-774-7175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS003800003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4372808Medicaid
2058285OtherPK