Provider Demographics
NPI:1518629591
Name:ESSENTIALRX
Entity Type:Organization
Organization Name:ESSENTIALRX
Other - Org Name:ESSENTIALRX LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:508-363-6602
Mailing Address - Street 1:123 SUMMER ST STE 365
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1216
Mailing Address - Country:US
Mailing Address - Phone:508-363-6602
Mailing Address - Fax:508-363-7602
Practice Address - Street 1:123 SUMMER ST STE 365
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-363-6602
Practice Address - Fax:508-363-7602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-07
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110163939AMedicaid