Provider Demographics
NPI:1083765903
Name:THEATRE PHARMACY INC
Entity Type:Organization
Organization Name:THEATRE PHARMACY INC
Other - Org Name:THEATRE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMELIO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:781-862-4480
Mailing Address - Street 1:1784 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-5302
Mailing Address - Country:US
Mailing Address - Phone:781-862-4480
Mailing Address - Fax:781-860-9567
Practice Address - Street 1:1784 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-5302
Practice Address - Country:US
Practice Address - Phone:781-862-4480
Practice Address - Fax:781-860-9567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA87613336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2208761OtherOTHER ID NUMBER
MA0414832Medicaid
0814700001Medicare NSC