Provider Demographics
NPI:1083723795
Name:PLAZA PHARMACY OF WESTPORT, INC.
Entity Type:Organization
Organization Name:PLAZA PHARMACY OF WESTPORT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:VINCELETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-673-5364
Mailing Address - Street 1:655 STATE RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790-2848
Mailing Address - Country:US
Mailing Address - Phone:508-673-5364
Mailing Address - Fax:508-673-7074
Practice Address - Street 1:655 STATE RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:MA
Practice Address - Zip Code:02790-2848
Practice Address - Country:US
Practice Address - Phone:508-673-5364
Practice Address - Fax:508-673-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2222333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0421251Medicaid
MA1052430001Medicare ID - Type Unspecified