Provider Demographics
NPI: | 1558496349 |
---|---|
Name: | MEDICINE SHOPPE MARLBORO INC |
Entity Type: | Organization |
Organization Name: | MEDICINE SHOPPE MARLBORO INC |
Other - Org Name: | MEDICINE STORE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PHARMACIST OWNER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | STEPHEN |
Authorized Official - Middle Name: | ALLEN |
Authorized Official - Last Name: | BIEBER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | RPH |
Authorized Official - Phone: | 508-481-2007 |
Mailing Address - Street 1: | 164 PLEASANT ST |
Mailing Address - Street 2: | |
Mailing Address - City: | MARLBOROUGH |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 01752-1117 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 508-481-5916 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 164 PLEASANT ST |
Practice Address - Street 2: | |
Practice Address - City: | MARLBOROUGH |
Practice Address - State: | MA |
Practice Address - Zip Code: | 01752-1117 |
Practice Address - Country: | US |
Practice Address - Phone: | 508-481-5916 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-02-22 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 9751 | 3336C0003X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |