Provider Demographics
NPI:1841385747
Name:MAHANT ENTERPRISES LLC
Entity Type:Organization
Organization Name:MAHANT ENTERPRISES LLC
Other - Org Name:GREEN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MINESH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAHMBHATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-665-0022
Mailing Address - Street 1:35 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-2811
Mailing Address - Country:US
Mailing Address - Phone:781-665-0022
Mailing Address - Fax:781-665-9461
Practice Address - Street 1:35 GREEN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2811
Practice Address - Country:US
Practice Address - Phone:781-665-0022
Practice Address - Fax:781-665-9461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MADS236123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0412163Medicaid
2041524OtherPK