Provider Demographics
NPI:1548375322
Name:MEDFORD SHOPRITE, INC.
Entity type:Organization
Organization Name:MEDFORD SHOPRITE, INC.
Other - Org Name:
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:732-521-8439
Mailing Address - Street 1:1230 BLACKWOOD CLEMENTON RD
Mailing Address - Street 2:
Mailing Address - City:CLEMENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-5632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 ROUTE 70
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-9522
Practice Address - Country:US
Practice Address - Phone:609-953-4723
Practice Address - Fax:609-953-4733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
NJRS005686333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7845405Medicaid
3140578OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NJ5958950001Medicare NSC