Provider Demographics
NPI:1912674417
Name:WHITTIER STREET HEALTH CENTER PHARMACY
Entity Type:Organization
Organization Name:WHITTIER STREET HEALTH CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP OF FINANCE AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-989-3230
Mailing Address - Street 1:1290 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3432
Mailing Address - Country:US
Mailing Address - Phone:617-427-1000
Mailing Address - Fax:617-989-3247
Practice Address - Street 1:1290 TREMONT ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02120-3432
Practice Address - Country:US
Practice Address - Phone:617-427-1000
Practice Address - Fax:617-989-3247
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITTIER STREET HEALTH CENTER COMMITTEE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110028189AMedicaid