Provider Demographics
NPI:1932556438
Name:PROCARE LTC OF MA LLC
Entity type:Organization
Organization Name:PROCARE LTC OF MA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:DR
Authorized Official - First Name:BINCY
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGHESE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:888-741-0367
Mailing Address - Street 1:1 OLYMPIC PL STE 600
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4110
Mailing Address - Country:US
Mailing Address - Phone:888-741-0367
Mailing Address - Fax:
Practice Address - Street 1:155 NORTHBORO RD STE 4
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1033
Practice Address - Country:US
Practice Address - Phone:508-481-5800
Practice Address - Fax:508-481-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-16
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336C0004X
MADS900423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110115534AMedicaid
2160164OtherPK