Healthcare Provider Details

I. General information

NPI: 1043965403
Provider Name (Legal Business Name): MEDWIZ OF MASS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 ELM ST
FOXBOROUGH MA
02035-2531
US

IV. Provider business mailing address

167 ROUTE 304
BARDONIA NY
10954-2050
US

V. Phone/Fax

Practice location:
  • Phone: 508-772-8600
  • Fax: 508-772-8601
Mailing address:
  • Phone: 508-772-8600
  • Fax: 508-772-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ERIC NEWHOUSE
Title or Position: CEO
Credential:
Phone: 845-624-8080