Provider Demographics
NPI:1366527657
Name:PORTEJAS CORP
Entity type:Organization
Organization Name:PORTEJAS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-867-6705
Mailing Address - Street 1:4207 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-4896
Mailing Address - Country:US
Mailing Address - Phone:201-867-6705
Mailing Address - Fax:201-867-3758
Practice Address - Street 1:4207 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-4896
Practice Address - Country:US
Practice Address - Phone:201-867-6705
Practice Address - Fax:201-867-3758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS005425003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2056801OtherPK
NJ7305001Medicaid
2056801OtherPK