Basic Information
| Provider Information | |||||||||
| NPI: | 1912674417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITTIER STREET HEALTH CENTER PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174271000 | ||||||||
| FaxNumber: | 6179893247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1290 TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174271000 | ||||||||
| FaxNumber: | 6179893247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2021 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP OF FINANCE AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 6179893230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHITTIER STREET HEALTH CENTER COMMITTEE INC | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 110028189A | 05 | MA | MEDICAID |