Healthcare Provider Details

I. General information

NPI: 1043343411
Provider Name (Legal Business Name): PAWTUXET VALLEY PRESCRIPTION & SURGICAL CENTER,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 SANDY BOTTOM RD
COVENTRY RI
02816-5863
US

IV. Provider business mailing address

59 SANDY BOTTOM RD
COVENTRY RI
02816-5863
US

V. Phone/Fax

Practice location:
  • Phone: 401-821-5000
  • Fax: 401-821-5016
Mailing address:
  • Phone: 401-821-5000
  • Fax: 401-821-5016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHA00001
License Number StateRI

VIII. Authorized Official

Name: MARK GILMORE
Title or Position: DIRECTOR OF OPERATIONS
Credential: RPH
Phone: 401-821-0600