Provider Demographics
NPI:1881817294
Name:NORTHEAST PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:NORTHEAST PHARMACY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FANARAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:603-224-9591
Mailing Address - Street 1:1 GRANITE PL
Mailing Address - Street 2:SUITE #200N
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-3258
Mailing Address - Country:US
Mailing Address - Phone:603-224-9591
Mailing Address - Fax:
Practice Address - Street 1:1 GRANITE PL
Practice Address - Street 2:SUITE #200N
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3258
Practice Address - Country:US
Practice Address - Phone:603-224-9591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0655P3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3077603Medicaid
NH5185210001Medicare NSC