Provider Demographics
NPI:1649363243
Name:REVERE HEALTH CENTER PHARMACY
Entity type:Organization
Organization Name:REVERE HEALTH CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS UNIT LEADER
Authorized Official - Prefix:MR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MS RPH
Authorized Official - Phone:617-724-9154
Mailing Address - Street 1:300 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151
Mailing Address - Country:US
Mailing Address - Phone:781-485-6098
Mailing Address - Fax:781-485-6042
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151
Practice Address - Country:US
Practice Address - Phone:781-485-6098
Practice Address - Fax:781-485-6042
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENERAL HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-02
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA0044987261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0445533Medicaid