Provider Demographics
NPI:1104901982
Name:BETH ISRAEL LAHEY HEALTH PHARMACY, INC.
Entity type:Organization
Organization Name:BETH ISRAEL LAHEY HEALTH PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIEF PHARMACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSENOR
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:781-352-6454
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8658
Mailing Address - Fax:781-744-5259
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8658
Practice Address - Fax:781-744-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA0050182333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADS100064OtherSTATE PHARMACY LICENSE
MA0419222Medicaid
MAMA0050904OtherMA CDS
MA0992350003Medicare NSC