Provider Demographics
NPI:1932207917
Name:PHARMAHEALTH HAWTHORNE INC
Entity Type:Organization
Organization Name:PHARMAHEALTH HAWTHORNE INC
Other - Org Name:PHARMAHEALTH HAWTHORN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVARES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:508-998-8000
Mailing Address - Street 1:132 ALDEN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-4721
Mailing Address - Country:US
Mailing Address - Phone:508-998-8000
Mailing Address - Fax:508-998-1145
Practice Address - Street 1:535 FAUNCE CORNER RD
Practice Address - Street 2:
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1242
Practice Address - Country:US
Practice Address - Phone:508-998-7888
Practice Address - Fax:508-998-9866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MA34733336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0423351Medicaid
2039593OtherPK
MA0423351Medicaid