Provider Demographics
NPI:1750600540
Name:GRUENBERG, JACK (R PH)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:GRUENBERG
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 FOURTH STREET
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-1902
Mailing Address - Country:US
Mailing Address - Phone:201-248-5207
Mailing Address - Fax:
Practice Address - Street 1:27 FOURTH STREET
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-1902
Practice Address - Country:US
Practice Address - Phone:201-248-5207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054468183500000X
NJ16429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist