Provider Demographics
NPI:1588689046
Name:DUANE READE
Entity type:Organization
Organization Name:DUANE READE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEMBHARD-PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-356-5227
Mailing Address - Street 1:PO BOX 2253
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10116-2253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:DUANE READE
Practice Address - Street 2:4901 BERGENLINE AVE
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093
Practice Address - Country:US
Practice Address - Phone:201-348-3884
Practice Address - Fax:201-348-3618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0613200333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8879907Medicaid
3144386OtherOTHER ID NUMBER-COMMERCIAL NUMBER