=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073188512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOSTON MEDICAL CENTER CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2021
-----------------------------------------------------
Last Update Date | 05/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 637 WASHINGTON ST
-----------------------------------------------------
City | DORCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02124-3510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-638-8150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 637 WASHINGTON ST
-----------------------------------------------------
City | DORCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02124-3510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-638-8150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. MANAGER OF PHARMACY REVENUE
-----------------------------------------------------
Name | TAFPHANE LEGRANDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-414-5393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------