Provider Demographics
NPI:1174805774
Name:CHANCELLOR PHARMACY
Entity type:Organization
Organization Name:CHANCELLOR PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:RINABEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-399-2700
Mailing Address - Street 1:894 CHANCELLOR AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-1214
Mailing Address - Country:US
Mailing Address - Phone:973-399-2700
Mailing Address - Fax:973-399-2701
Practice Address - Street 1:894 CHANCELLOR AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-1214
Practice Address - Country:US
Practice Address - Phone:973-399-2700
Practice Address - Fax:973-399-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-09
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS007142003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0290017Medicaid
2131872OtherPK
NJ6632030001Medicare NSC