Provider Demographics
NPI:1629138920
Name:EGLESTON SQUARE PHARMACY,INC.
Entity Type:Organization
Organization Name:EGLESTON SQUARE PHARMACY,INC.
Other - Org Name:EGLESTON SQUARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALOYSIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ONUJIOGUS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:617-442-6070
Mailing Address - Street 1:3090 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3115
Mailing Address - Country:US
Mailing Address - Phone:617-442-6070
Mailing Address - Fax:617-442-3424
Practice Address - Street 1:3090 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-3115
Practice Address - Country:US
Practice Address - Phone:617-442-6070
Practice Address - Fax:617-442-3424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA332B00000X
MA33663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0406911Medicaid
MA0406911Medicaid