Provider Demographics
NPI:1306943238
Name:STAFFORD PHARMACY INC
Entity type:Organization
Organization Name:STAFFORD PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GENCO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:609-597-9625
Mailing Address - Street 1:24 NAUTILUS DR
Mailing Address - Street 2:UNIT 1
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2490
Mailing Address - Country:US
Mailing Address - Phone:609-597-9625
Mailing Address - Fax:609-597-0047
Practice Address - Street 1:24 NAUTILUS DR
Practice Address - Street 2:UNIT 1
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2490
Practice Address - Country:US
Practice Address - Phone:609-597-9625
Practice Address - Fax:609-597-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS004821003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4346807Medicaid
2057891OtherPK
0570810001Medicare NSC