Provider Demographics
NPI:1396914156
Name:DRUG FAIR OF EAST RUTHERFOD
Entity type:Organization
Organization Name:DRUG FAIR OF EAST RUTHERFOD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LABEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-748-8900
Mailing Address - Street 1:LIBERTY COMMONS 51 ROUTE 17 SOUTH
Mailing Address - Street 2:
Mailing Address - City:EAST RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LIBERTY COMMONS 51 ROUTE 17 SOUTH
Practice Address - Street 2:
Practice Address - City:EAST RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07073
Practice Address - Country:US
Practice Address - Phone:201-531-9901
Practice Address - Fax:210-531-9919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NJ28RS006784003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
3194999OtherOTHER ID NUMBER