Healthcare Provider Details

I. General information

NPI: 1821379298
Provider Name (Legal Business Name): MOMS PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 AMORY ST
ROXBURY MA
02119-1051
US

IV. Provider business mailing address

75 AMORY ST
ROXBURY MA
02119-1051
US

V. Phone/Fax

Practice location:
  • Phone: 617-708-3922
  • Fax: 617-708-3999
Mailing address:
  • Phone: 617-708-3922
  • Fax: 617-708-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GLENN SCHABEL
Title or Position: GENERAL MANAGER
Credential: R.PH.
Phone: 631-870-5129