Provider Demographics
NPI:1881781078
Name:ROSLINDALE PHARMACY LTD
Entity type:Organization
Organization Name:ROSLINDALE PHARMACY LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR OF PHARM
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:OKWESILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-325-0300
Mailing Address - Street 1:452 HYDE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3131
Mailing Address - Country:US
Mailing Address - Phone:617-325-0300
Mailing Address - Fax:617-325-2240
Practice Address - Street 1:452 HYDE PARK AVE
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-3131
Practice Address - Country:US
Practice Address - Phone:617-325-0300
Practice Address - Fax:617-325-2240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MA29733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0448443Medicaid
2038795OtherPK
MA0448443Medicaid