Provider Demographics
NPI:1225182595
Name:VILLAGE FERTILITY PHARMACY, LLC
Entity Type:Organization
Organization Name:VILLAGE FERTILITY PHARMACY, LLC
Other - Org Name:VILLAGE PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF REGULATORY AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-810-4147
Mailing Address - Street 1:335 BEAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1006
Mailing Address - Country:US
Mailing Address - Phone:877-334-1610
Mailing Address - Fax:877-334-1602
Practice Address - Street 1:335 BEAR HILL RD
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1006
Practice Address - Country:US
Practice Address - Phone:877-334-1610
Practice Address - Fax:877-334-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADS900593336C0003X, 3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110119927AMedicaid