Healthcare Provider Details

I. General information

NPI: 1326155458
Provider Name (Legal Business Name): THE COMMONWEALTH OF MASSACHUSETTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 QUINCY ST
BROCKTON MA
02302-2988
US

IV. Provider business mailing address

165 QUINCY ST
BROCKTON MA
02302-2988
US

V. Phone/Fax

Practice location:
  • Phone: 508-897-2069
  • Fax:
Mailing address:
  • Phone: 508-897-2069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateMA

VIII. Authorized Official

Name: MONA MACKINNON
Title or Position: CENTER DIRECTOR
Credential:
Phone: 774-297-3246