Provider Demographics
NPI:1639351364
Name:PEARL STREET PHARMACY
Entity Type:Organization
Organization Name:PEARL STREET PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROCKY
Authorized Official - Middle Name:
Authorized Official - Last Name:TENGALIA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:781-925-2378
Mailing Address - Street 1:1 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-2864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2864
Practice Address - Country:US
Practice Address - Phone:508-588-7455
Practice Address - Fax:508-588-7400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADS35653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2242155OtherOTHER ID NUMBER