Provider Demographics
NPI:1740615251
Name:NKANYIMUO REAL ESTATE LLC
Entity Type:Organization
Organization Name:NKANYIMUO REAL ESTATE LLC
Other - Org Name:BLUE HILL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:OKEKE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:617-652-7546
Mailing Address - Street 1:BLUE HILL PHARMACY
Mailing Address - Street 2:320 BLUE HILL AVE.
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121-1951
Mailing Address - Country:US
Mailing Address - Phone:617-652-7546
Mailing Address - Fax:617-652-7561
Practice Address - Street 1:320 BLUE HILL AVE
Practice Address - Street 2:STORE
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-1951
Practice Address - Country:US
Practice Address - Phone:617-652-7546
Practice Address - Fax:617-652-7561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-04
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADS899423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110102251AMedicaid
2141994OtherPK