Provider Demographics
NPI:1821139023
Name:WORCESTER PHARMACY LLC
Entity Type:Organization
Organization Name:WORCESTER PHARMACY LLC
Other - Org Name:BOULEVARD PHARMACEUTICAL COMPOUNDING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUKHATEM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:617-599-2793
Mailing Address - Street 1:149 SHREWSBURY ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-4637
Mailing Address - Country:US
Mailing Address - Phone:508-754-1791
Mailing Address - Fax:508-795-0813
Practice Address - Street 1:149 SHREWSBURY ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-4637
Practice Address - Country:US
Practice Address - Phone:508-754-1791
Practice Address - Fax:508-795-0813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2943291U00000X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No291U00000XLaboratoriesClinical Medical Laboratory