Provider Demographics
NPI:1659465326
Name:SUTHERLAND PHARMACY LLC
Entity Type:Organization
Organization Name:SUTHERLAND PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEARY
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:617-232-3513
Mailing Address - Street 1:1690 COMMONWEALTH AVE.
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5602
Mailing Address - Country:US
Mailing Address - Phone:617-232-3513
Mailing Address - Fax:617-232-1569
Practice Address - Street 1:1690 COMMONWEALTH AVE.
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-5602
Practice Address - Country:US
Practice Address - Phone:617-232-3513
Practice Address - Fax:617-232-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0400076Medicaid
MA2204662OtherNABP NUMBER
0466450001Medicare ID - Type UnspecifiedMEDICARE NUMBER