Provider Demographics
NPI:1013392117
Name:BAYSTATE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:BAYSTATE MEDICAL CENTER INC
Other - Org Name:BAYSTATE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PHARMACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-794-3178
Mailing Address - Street 1:759 CHESTNUT STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01101
Mailing Address - Country:US
Mailing Address - Phone:413-794-3291
Mailing Address - Fax:413-794-9377
Practice Address - Street 1:759 CHESTNUT ST
Practice Address - Street 2:DALY 3 PHARMACY
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-1001
Practice Address - Country:US
Practice Address - Phone:413-794-3291
Practice Address - Fax:413-794-9377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADS899123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110098563/DMedicaid
FB4889210OtherDEA