Provider Demographics
NPI:1487060109
Name:SHREE GANESH PHARMACY LLC
Entity type:Organization
Organization Name:SHREE GANESH PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JIGNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-471-9100
Mailing Address - Street 1:625 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4952
Mailing Address - Country:US
Mailing Address - Phone:973-471-9100
Mailing Address - Fax:973-471-9900
Practice Address - Street 1:625 MAIN AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4952
Practice Address - Country:US
Practice Address - Phone:973-471-9100
Practice Address - Fax:973-471-9900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NJ28RS007340003336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0482072Medicaid
2144574OtherPK