Provider Demographics
NPI:1699152751
Name:FENNY PHARMACY LLC
Entity type:Organization
Organization Name:FENNY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:BADRINATH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGGARAM RAMAMOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-333-2223
Mailing Address - Street 1:129 NEWARK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-2811
Mailing Address - Country:US
Mailing Address - Phone:201-333-2223
Mailing Address - Fax:201-333-2224
Practice Address - Street 1:129 NEWARK AVE STE 2
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-2811
Practice Address - Country:US
Practice Address - Phone:201-333-2223
Practice Address - Fax:201-333-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS006643003336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151399OtherPK
NJ0123528Medicaid
2151399OtherPK