Provider Demographics
NPI:1598889172
Name:PELHAM COMMUNITY PHARMACY, INC
Entity Type:Organization
Organization Name:PELHAM COMMUNITY PHARMACY, INC
Other - Org Name:PELHAM COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BHUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-966-2700
Mailing Address - Street 1:21 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1646
Mailing Address - Country:US
Mailing Address - Phone:781-966-2700
Mailing Address - Fax:781-890-0234
Practice Address - Street 1:21 GREEN ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1646
Practice Address - Country:US
Practice Address - Phone:781-966-2700
Practice Address - Fax:781-890-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336C0004X
MADS896473336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0407810Medicaid
2237837OtherNCPDP PROVIDER IDENTIFICATION NUMBER