Healthcare Provider Details

I. General information

NPI: 1871007443
Provider Name (Legal Business Name): HAWTHORN PHARMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2017
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 ROCKDALE AVE
NEW BEDFORD MA
02740-2701
US

IV. Provider business mailing address

827 ROCKDALE AVE
NEW BEDFORD MA
02740-2701
US

V. Phone/Fax

Practice location:
  • Phone: 508-998-7888
  • Fax: 508-997-9866
Mailing address:
  • Phone: 508-998-7888
  • Fax: 508-998-9866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. SREENIVAS ATHULURI
Title or Position: PHARMACIST
Credential:
Phone: 508-998-7888