=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679621676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME DRUG INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 05/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 CRANSTON ST
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02907-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-521-9660
-----------------------------------------------------
Fax | 401-861-1177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 613 CRANSTON ST
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02907-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | CARMINE DETOMASIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-521-9660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHA00075
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------