Provider Demographics
NPI:1205020278
Name:PEPPERELL PHARMACY INC
Entity Type:Organization
Organization Name:PEPPERELL PHARMACY INC
Other - Org Name:PEPPERELL FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:EZZIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-433-6130
Mailing Address - Street 1:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:PEPPERELL
Mailing Address - State:MA
Mailing Address - Zip Code:01463-3547
Mailing Address - Country:US
Mailing Address - Phone:978-433-6130
Mailing Address - Fax:978-433-1881
Practice Address - Street 1:74 MAIN ST
Practice Address - Street 2:
Practice Address - City:PEPPERELL
Practice Address - State:MA
Practice Address - Zip Code:01463-1560
Practice Address - Country:US
Practice Address - Phone:978-433-6130
Practice Address - Fax:978-433-1881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MADS35413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2039732OtherPK
MA041557Medicaid