Provider Demographics
NPI:1184853723
Name:FISHERVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:FISHERVILLE PHARMACY LLC
Other - Org Name:FISHERVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVADIAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:603-565-0210
Mailing Address - Street 1:219 FISHERVILLE RD
Mailing Address - Street 2:#C
Mailing Address - City:PENACOOK
Mailing Address - State:NH
Mailing Address - Zip Code:03303-2074
Mailing Address - Country:US
Mailing Address - Phone:603-565-0210
Mailing Address - Fax:603-565-0214
Practice Address - Street 1:219 FISHERVILLE RD
Practice Address - Street 2:
Practice Address - City:PENACOOK
Practice Address - State:NH
Practice Address - Zip Code:03303-2074
Practice Address - Country:US
Practice Address - Phone:603-565-0210
Practice Address - Fax:603-565-0214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-03
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
NH07613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120912OtherPK
NH30707542Medicaid
NH6787740001Medicare NSC