Provider Demographics
NPI:1235239252
Name:PERROTTA'S PHARMACY
Entity Type:Organization
Organization Name:PERROTTA'S PHARMACY
Other - Org Name:PERROTTA'S SUPER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PERROTTA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:978-682-2557
Mailing Address - Street 1:292 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-2825
Mailing Address - Country:US
Mailing Address - Phone:978-682-2557
Mailing Address - Fax:978-685-7597
Practice Address - Street 1:292 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-2825
Practice Address - Country:US
Practice Address - Phone:978-682-2557
Practice Address - Fax:978-685-7597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MA12003336C0003X, 3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0430374Medicaid
MA0758930001Medicare NSC
758930001Medicare ID - Type Unspecified