1962505776 NPI number — HEALTHSTAR PHARMACY INC.

Table of content: (NPI 1962505776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962505776 NPI number — HEALTHSTAR PHARMACY INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHSTAR PHARMACY INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LENOX VILLAGE PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962505776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 WALKER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENOX
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01240-2723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-637-4700
Provider Business Mailing Address Fax Number:
413-637-4781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 WALKER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LENOX
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01240-2723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-637-4700
Provider Business Practice Location Address Fax Number:
413-637-4781
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTRAGONO
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
413-637-4700

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  3344 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 3344 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003125566 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001079607 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0050679 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30703172 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02586056 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010267421 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0404098 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1010874 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4058950 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: PH143MA , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP54396 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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