Basic Information
| Provider Information | |||||||||
| NPI: | 1326405622 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENRY J. AUSTIN HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HENRY J. AUSTIN PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 321 N WARREN ST | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086184741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092785931 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 321 N WARREN ST | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086184741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092785931 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2016 | ||||||||
| LastUpdateDate: | 02/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | ALLI | ||||||||
| AuthorizedOfficialFirstName: | KEMI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO, CMO | ||||||||
| AuthorizedOfficialTelephone: | 6092785939 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | 28RS00746300 | NJ | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2157612 | 01 | PK | OTHER |