Provider Demographics
NPI:1386903391
Name:BRUNSWICK SQUARE PHARMACY
Entity type:Organization
Organization Name:BRUNSWICK SQUARE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKAILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-726-3033
Mailing Address - Street 1:12 BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-1614
Mailing Address - Country:US
Mailing Address - Phone:732-257-5200
Mailing Address - Fax:732-257-2600
Practice Address - Street 1:1177 STATE ROUTE 18
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-4935
Practice Address - Country:US
Practice Address - Phone:732-257-5200
Practice Address - Fax:732-257-2600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007189003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135495OtherPK