Provider Demographics
NPI:1437282803
Name:PAWTUXET VALLEY PRESCRIPTION & SURGICAL CENTER,INC
Entity Type:Organization
Organization Name:PAWTUXET VALLEY PRESCRIPTION & SURGICAL CENTER,INC
Other - Org Name:PAWTUXET VALLEY LONG TERM CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
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 1:65 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:401-823-9400
Mailing Address - Fax:410-822-0262
Practice Address - Street 1:65 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:401-823-9400
Practice Address - Fax:410-822-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPHA000013336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI4103406OtherNCPDP
RIPHA00001OtherLICENSE #
RIPHA00001OtherLICENSE #