=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437282803
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAWTUXET VALLEY PRESCRIPTION & SURGICAL CENTER,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 SANDY BOTTOM RD
-----------------------------------------------------
City | COVENTRY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02816-5863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-823-9400
-----------------------------------------------------
Fax | 410-822-0262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 SANDY BOTTOM RD
-----------------------------------------------------
City | COVENTRY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02816-5863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-823-9400
-----------------------------------------------------
Fax | 410-822-0262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MARK GILMORE
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 401-821-0600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | PHA00001
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------