Provider Demographics
NPI:1417068560
Name:BOORAS MEDICAL SUPPLY
Entity Type:Organization
Organization Name:BOORAS MEDICAL SUPPLY
Other - Org Name:OSBORNE MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PRES
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAMS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOORAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-598-3501
Mailing Address - Street 1:59 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-1712
Mailing Address - Country:US
Mailing Address - Phone:781-598-3501
Mailing Address - Fax:781-598-3552
Practice Address - Street 1:59 ESSEX ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-1712
Practice Address - Country:US
Practice Address - Phone:781-598-3501
Practice Address - Fax:781-598-3552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MA93213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0411159Medicaid
2209321OtherNCPDP PROVIDER IDENTIFICATION NUMBER
2209321OtherNCPDP PROVIDER IDENTIFICATION NUMBER