Provider Demographics
NPI:1558443341
Name:EDLINE GROUP INCORPORATED
Entity Type:Organization
Organization Name:EDLINE GROUP INCORPORATED
Other - Org Name:COMPTON DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:OBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-288-1616
Mailing Address - Street 1:393 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2415
Mailing Address - Country:US
Mailing Address - Phone:617-288-1616
Mailing Address - Fax:617-506-6003
Practice Address - Street 1:393 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-2415
Practice Address - Country:US
Practice Address - Phone:617-288-1616
Practice Address - Fax:617-506-6003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MA33253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2227812OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MA0406350Medicaid
2227812OtherNCPDP PROVIDER IDENTIFICATION NUMBER