Provider Demographics
NPI:1568876589
Name:SOUTHCOAST HOSPITALS GROUP, INC
Entity Type:Organization
Organization Name:SOUTHCOAST HOSPITALS GROUP, INC
Other - Org Name:SOUTHCOAST SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP-CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:DUDLEY
Authorized Official - Last Name:BROUGHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-973-2908
Mailing Address - Street 1:206 MILL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5208
Mailing Address - Country:US
Mailing Address - Phone:508-973-3320
Mailing Address - Fax:508-973-3325
Practice Address - Street 1:206 MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-5208
Practice Address - Country:US
Practice Address - Phone:508-973-3320
Practice Address - Fax:508-973-3325
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHCOAST HOSPITALS GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-18
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAV113333600000X, 3336S0011X
333600000X, 3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1977460003Medicare NSC