Provider Demographics
NPI:1255425203
Name:PROFESSIONAL PHARMACY
Entity type:Organization
Organization Name:PROFESSIONAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCH
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:781-235-8144
Mailing Address - Street 1:183 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-7909
Mailing Address - Country:US
Mailing Address - Phone:781-235-8144
Mailing Address - Fax:781-235-2315
Practice Address - Street 1:183 LINDEN ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-7909
Practice Address - Country:US
Practice Address - Phone:781-235-8144
Practice Address - Fax:781-235-2315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA144593336C0003X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0412074OtherMA PROVIDER #
MA22-14459OtherNADP#
MAAP1925380OtherD.E.A.#
MA0370850001Medicare ID - Type UnspecifiedMEDICARE #