Provider Demographics
NPI:1235316910
Name:WEST RIVER PHARM INC
Entity Type:Organization
Organization Name:WEST RIVER PHARM INC
Other - Org Name:WEST RIVER PHARM INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-573-5211
Mailing Address - Street 1:140 LOCKE DR
Mailing Address - Street 2:STE C
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-7230
Mailing Address - Country:US
Mailing Address - Phone:508-573-5200
Mailing Address - Fax:508-490-8560
Practice Address - Street 1:140 LOCKE DR
Practice Address - Street 2:STE C
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-7230
Practice Address - Country:US
Practice Address - Phone:508-573-5200
Practice Address - Fax:508-490-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MA35723336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2039746OtherPK
MA6090670001Medicare NSC
2242218OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CTP008001855Medicaid
MADS3572OtherPHARMACY LICENSE NUMBER
MA11078309AMedicaid
MA0409189Medicaid
MACS3572OtherPHARMACY CONTROLLED SUBSTANCE PERMIT
ME432916300Medicaid