Provider Demographics
NPI:1629013149
Name:BROWN UNIVERSITY OF PROVEDENCE STATE OF RI AND PROV PLANTAIO
Entity Type:Organization
Organization Name:BROWN UNIVERSITY OF PROVEDENCE STATE OF RI AND PROV PLANTAIO
Other - Org Name:BROWN UNIVERSITY STUDENT HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-863-7882
Mailing Address - Street 1:13 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02912-9006
Mailing Address - Country:US
Mailing Address - Phone:401-863-7882
Mailing Address - Fax:401-863-2178
Practice Address - Street 1:450 BROOK STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02912-9006
Practice Address - Country:US
Practice Address - Phone:401-863-7882
Practice Address - Fax:401-863-2178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
RIPHB000243336I0012X, 3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2088775OtherPK
4104193OtherOTHER ID NUMBER