Provider Demographics
NPI:1740387562
Name:MELROSE DRUG CENTER INC
Entity Type:Organization
Organization Name:MELROSE DRUG CENTER INC
Other - Org Name:MELROSE DRUG CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-665-7400
Mailing Address - Street 1:462 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3842
Mailing Address - Country:US
Mailing Address - Phone:781-665-7400
Mailing Address - Fax:781-665-7940
Practice Address - Street 1:462 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3842
Practice Address - Country:US
Practice Address - Phone:781-665-7400
Practice Address - Fax:781-665-7940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MA20623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0497517Medicaid
2202062OtherNCPDP PROVIDER IDENTIFICATION NUMBER