Provider Demographics
NPI:1851492078
Name:LIBUN APOTHECARY & SURGICAL SUPPLY, INC
Entity Type:Organization
Organization Name:LIBUN APOTHECARY & SURGICAL SUPPLY, INC
Other - Org Name:BAXTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:LIBBY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:617-773-7733
Mailing Address - Street 1:464 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5716
Mailing Address - Country:US
Mailing Address - Phone:617-773-7733
Mailing Address - Fax:617-773-8372
Practice Address - Street 1:464 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5716
Practice Address - Country:US
Practice Address - Phone:617-773-7733
Practice Address - Fax:617-773-8372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3502332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0408247Medicaid
MA2225921OtherNABP
MA3502OtherLICENSE
MA2225921OtherNABP