Provider Demographics
NPI:1538473269
Name:STEWARD ST ELIZABETHS MEDICAL CENTER OF BOSTON INC
Entity Type:Organization
Organization Name:STEWARD ST ELIZABETHS MEDICAL CENTER OF BOSTON INC
Other - Org Name:BRIGHTON MARINE PHARMACY AT HANSCOM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GERMANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-562-5302
Mailing Address - Street 1:1609 EGLIN ST
Mailing Address - Street 2:
Mailing Address - City:HANSCOM AFB
Mailing Address - State:MA
Mailing Address - Zip Code:01731-2613
Mailing Address - Country:US
Mailing Address - Phone:781-274-9102
Mailing Address - Fax:781-274-6249
Practice Address - Street 1:1609 EGLIN ST
Practice Address - Street 2:
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731-2613
Practice Address - Country:US
Practice Address - Phone:781-274-9102
Practice Address - Fax:781-274-6249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA00588613336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128072OtherPK