Provider Demographics
NPI:1043359854
Name:CARITAS ST ELIZABETH HEALTH CARE
Entity Type:Organization
Organization Name:CARITAS ST ELIZABETH HEALTH CARE
Other - Org Name:BRIGHTON MARINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY MGR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GERMANO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:617-562-5302
Mailing Address - Street 1:77 WARREN ST
Mailing Address - Street 2:PHCY DEPT
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 WARREN ST
Practice Address - Street 2:PHCY DEPT
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3601
Practice Address - Country:US
Practice Address - Phone:617-562-5304
Practice Address - Fax:617-562-5296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 3336C0004X, 3336M0002X, 3336S0011X
MAMA01488483336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2226175OtherOTHER ID NUMBER
MA0401200Medicaid
2226175OtherOTHER ID NUMBER-COMMERCIAL NUMBER