Provider Demographics
NPI:1295171825
Name:MARS, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MARS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-1150
Mailing Address - Country:US
Mailing Address - Phone:201-436-5875
Mailing Address - Fax:201-436-4063
Practice Address - Street 1:110 W 4TH ST
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-1150
Practice Address - Country:US
Practice Address - Phone:201-436-5875
Practice Address - Fax:201-436-4063
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02918900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0308919Medicaid
NJ0308919OtherPAAD