Provider Demographics
NPI:1699810770
Name:VILLAGE SUPER MARKET OF NJ LP
Entity type:Organization
Organization Name:VILLAGE SUPER MARKET OF NJ LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8448
Mailing Address - Street 1:23 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-1601
Mailing Address - Country:US
Mailing Address - Phone:609-927-0760
Mailing Address - Fax:609-926-2226
Practice Address - Street 1:23 BETHEL RD
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-1601
Practice Address - Country:US
Practice Address - Phone:609-927-0760
Practice Address - Fax:609-926-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRS0038393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4376501Medicaid
NJ3122140OtherNCPDP
NJ4376501Medicaid