Provider Demographics
NPI:1871812420
Name:MEDCO HEALTH SOLUTIONS OF WILLINGBORO, LLC
Entity type:Organization
Organization Name:MEDCO HEALTH SOLUTIONS OF WILLINGBORO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CESANEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-880-2307
Mailing Address - Street 1:1 MILLENIUM DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-1000
Mailing Address - Country:US
Mailing Address - Phone:877-807-0947
Mailing Address - Fax:609-880-2221
Practice Address - Street 1:1 MILLENIUM DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1000
Practice Address - Country:US
Practice Address - Phone:877-807-0947
Practice Address - Fax:609-880-2221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00701500333600000X
3336C0003X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124850OtherPK