Provider Demographics
NPI:1245650225
Name:BAYSTATE PHARMACY
Entity type:Organization
Organization Name:BAYSTATE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACY OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-794-3178
Mailing Address - Street 1:PO BOX 798
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01101-0798
Mailing Address - Country:US
Mailing Address - Phone:413-794-9009
Mailing Address - Fax:413-794-9013
Practice Address - Street 1:50 WASON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1132
Practice Address - Country:US
Practice Address - Phone:413-794-9009
Practice Address - Fax:413-794-9013
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAYSTATE MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADS898963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MACS89896OtherCONTROLLED SUBSTANCE REGISTRATION
MADS89896OtherMA DRUG STORE NUMBER
MADS89896OtherMA DRUG STORE NUMBER