Provider Demographics
NPI:1225363229
Name:SUGAR RIVER PHARMACY LLC
Entity Type:Organization
Organization Name:SUGAR RIVER PHARMACY LLC
Other - Org Name:SUGAR RIVER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BEANE
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MBA
Authorized Official - Phone:603-863-4111
Mailing Address - Street 1:54 JOHN STARK HWY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NH
Mailing Address - Zip Code:03773-1811
Mailing Address - Country:US
Mailing Address - Phone:603-863-4111
Mailing Address - Fax:603-863-4533
Practice Address - Street 1:54 JOHN STARK HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:NH
Practice Address - Zip Code:03773-1811
Practice Address - Country:US
Practice Address - Phone:603-863-4111
Practice Address - Fax:603-863-4533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NH07633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122307OtherPK
NH=========Medicaid