Provider Demographics
NPI:1598858938
Name:ATHOL FAMILY PHARMACY INCORPORATED
Entity Type:Organization
Organization Name:ATHOL FAMILY PHARMACY INCORPORATED
Other - Org Name:ATHOL FAMILY PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAMID
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAGHEGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-755-4173
Mailing Address - Street 1:100 GROVE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2627
Mailing Address - Country:US
Mailing Address - Phone:508-755-4173
Mailing Address - Fax:508-755-4173
Practice Address - Street 1:321 MAIN ST
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331-2233
Practice Address - Country:US
Practice Address - Phone:978-249-9100
Practice Address - Fax:978-249-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADS34803336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110074420/AMedicaid
2039595OtherPK