Provider Demographics
NPI: | 1568146991 |
---|---|
Name: | WALTHAM DRUG, LLC. |
Entity Type: | Organization |
Organization Name: | WALTHAM DRUG, LLC. |
Other - Org Name: | WATCH CITY PHARMACY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | MANAGER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | OLEG |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | URIM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | RPH |
Authorized Official - Phone: | 781-405-3228 |
Mailing Address - Street 1: | 923 MAIN ST |
Mailing Address - Street 2: | |
Mailing Address - City: | WALTHAM |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02451-7416 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 617-472-2281 |
Mailing Address - Fax: | 781-790-8914 |
Practice Address - Street 1: | 923 MAIN ST |
Practice Address - Street 2: | |
Practice Address - City: | WALTHAM |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02451-7416 |
Practice Address - Country: | US |
Practice Address - Phone: | 617-472-2281 |
Practice Address - Fax: | 781-790-8914 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2023-06-14 |
Last Update Date: | 2023-12-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |
No | 333600000X | Suppliers | Pharmacy | |
No | 3336L0003X | Suppliers | Pharmacy | Long Term Care Pharmacy |