Provider Demographics
NPI:1346373792
Name:PAWTUXET VALLEY PRESCRIPTION & SURGICAL CENTER,INC
Entity Type:Organization
Organization Name:PAWTUXET VALLEY PRESCRIPTION & SURGICAL CENTER,INC
Other - Org Name:PAWTUXET VALLEY IDME
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:401-821-0600
Mailing Address - Street 1:59 SANDY BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-5863
Mailing Address - Country:US
Mailing Address - Phone:401-821-5000
Mailing Address - Fax:401-821-5016
Practice Address - Street 1:59 SANDY BOTTOM RD
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-5863
Practice Address - Country:US
Practice Address - Phone:401-821-5000
Practice Address - Fax:401-821-5016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPHA00001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9010107Medicaid
RI75763OtherBLUE CROSS #
RI75763OtherBLUE CROSS #