Provider Demographics
NPI:1326615758
Name:FAIRHAVEN PHARMACY, INC
Entity Type:Organization
Organization Name:FAIRHAVEN PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MENESES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:508-525-4455
Mailing Address - Street 1:72 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-3041
Mailing Address - Country:US
Mailing Address - Phone:508-525-4455
Mailing Address - Fax:
Practice Address - Street 1:72 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-3041
Practice Address - Country:US
Practice Address - Phone:508-525-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy