Provider Demographics
NPI:1184899957
Name:FENWAY COMMUNITY HEALTH CENTER INC
Entity type:Organization
Organization Name:FENWAY COMMUNITY HEALTH CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MELE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:617-927-6330
Mailing Address - Street 1:142 BERKELEY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5100
Mailing Address - Country:US
Mailing Address - Phone:617-927-6163
Mailing Address - Fax:617-267-1113
Practice Address - Street 1:142 BERKELEY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5100
Practice Address - Country:US
Practice Address - Phone:617-927-6163
Practice Address - Fax:617-267-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADS35833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2039754OtherPK
MA110020739EMedicaid