Provider Demographics
NPI:1831461086
Name:UMASS MEMORIAL MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:UMASS MEMORIAL MEDICAL CENTER, INC.
Other - Org Name:UMASS MEMORIAL MEDICAL CENTER SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, SPECIALTY PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-740-8131
Mailing Address - Street 1:55 LAKE AVE N
Mailing Address - Street 2:SUITE AC1.033
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655-0002
Mailing Address - Country:US
Mailing Address - Phone:888-639-3988
Mailing Address - Fax:866-344-0186
Practice Address - Street 1:55 LAKE AVE N STE AC1.033
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:888-639-3988
Practice Address - Fax:866-344-0186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADS898223336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110093140Medicaid
2135484OtherPK
MA110093140Medicaid