Provider Demographics
NPI:1336145820
Name:NORTHEAST PHARMACY SERVICES, LLC
Entity Type:Organization
Organization Name:NORTHEAST PHARMACY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FRAZEE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:603-226-8686
Mailing Address - Street 1:125 N MAIN ST
Mailing Address - Street 2:STE 2
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-4921
Mailing Address - Country:US
Mailing Address - Phone:603-226-8686
Mailing Address - Fax:603-225-6579
Practice Address - Street 1:125 N MAIN ST
Practice Address - Street 2:STE 2
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-4921
Practice Address - Country:US
Practice Address - Phone:603-226-8686
Practice Address - Fax:603-225-6579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0655-P183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30702975Medicaid