Provider Demographics
NPI:1295218964
Name:BROCKTON PHARMACY, LLC
Entity Type:Organization
Organization Name:BROCKTON PHARMACY, LLC
Other - Org Name:BRIGHT HEALTH PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:N
Authorized Official - Last Name:ALAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MBA, RPH
Authorized Official - Phone:774-517-5528
Mailing Address - Street 1:90 MAIN ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4011
Mailing Address - Country:US
Mailing Address - Phone:774-517-5528
Mailing Address - Fax:774-517-5568
Practice Address - Street 1:90 MAIN ST UNIT A
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4011
Practice Address - Country:US
Practice Address - Phone:774-517-5528
Practice Address - Fax:774-517-5568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-10
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110148058AMedicaid