Healthcare Provider Details

I. General information

NPI: 1083765903
Provider Name (Legal Business Name): THEATRE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1784 MASSACHUSETTS AVE
LEXINGTON MA
02420-5302
US

IV. Provider business mailing address

1784 MASSACHUSETTS AVE
LEXINGTON MA
02420-5302
US

V. Phone/Fax

Practice location:
  • Phone: 781-862-4480
  • Fax: 781-860-9567
Mailing address:
  • Phone: 781-862-4480
  • Fax: 781-860-9567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number8761
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN CAMELIO
Title or Position: PHARMACIST
Credential: RPH.
Phone: 781-862-4480