Provider Demographics
NPI:1396870986
Name:IMPRIMISRX NJ, LLC
Entity type:Organization
Organization Name:IMPRIMISRX NJ, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-704-4040
Mailing Address - Street 1:1000 AVIARA DR STE 220
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-4218
Mailing Address - Country:US
Mailing Address - Phone:858-704-4040
Mailing Address - Fax:858-345-1745
Practice Address - Street 1:1705 ROUTE 46 STE 4
Practice Address - Street 2:
Practice Address - City:LEDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07852-9720
Practice Address - Country:US
Practice Address - Phone:844-446-6979
Practice Address - Fax:855-405-4669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS005933003336C0003X, 3336C0004X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3143017OtherNCPDP