Provider Demographics
NPI:1689965261
Name:ROYAL PALM SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:ROYAL PALM SPECIALTY PHARMACY LLC
Other - Org Name:ROYAL PALM SPECIALTY PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:508-461-4045
Mailing Address - Street 1:118 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01570-5205
Mailing Address - Country:US
Mailing Address - Phone:508-461-4045
Mailing Address - Fax:508-461-4044
Practice Address - Street 1:118 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:MA
Practice Address - Zip Code:01570-5205
Practice Address - Country:US
Practice Address - Phone:508-461-4045
Practice Address - Fax:508-461-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADS897653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2243537OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MA6707940001Medicare NSC