1740615251 NPI number — NKANYIMUO REAL ESTATE LLC

Table of content: (NPI 1740615251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740615251 NPI number — NKANYIMUO REAL ESTATE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NKANYIMUO REAL ESTATE LLC
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:
Provider Other Organization Name Type Code:
6
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:
1740615251
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BLUE HILL PHARMACY
Provider Second Line Business Mailing Address:
320 BLUE HILL AVE.
Provider Business Mailing Address City Name:
DORCHESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02121-1951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-652-7546
Provider Business Mailing Address Fax Number:
617-652-7561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 BLUE HILL AVE
Provider Second Line Business Practice Location Address:
STORE
Provider Business Practice Location Address City Name:
DORCHESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02121-1951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-652-7546
Provider Business Practice Location Address Fax Number:
617-652-7561
Provider Enumeration Date:
09/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
OKEKE
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER/ PHARMACIST-IN-CHARGE
Authorized Official Telephone Number:
617-652-7546

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  DS89942 , 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: 110102251A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2141994 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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