Provider Demographics
NPI:1609215946
Name:BELMONT PHARMACY LLC
Entity type:Organization
Organization Name:BELMONT PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / PIC
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-489-1616
Mailing Address - Street 1:246 TRAPELO RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1849
Mailing Address - Country:US
Mailing Address - Phone:617-489-1616
Mailing Address - Fax:617-489-1066
Practice Address - Street 1:246 TRAPELO RD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-1849
Practice Address - Country:US
Practice Address - Phone:617-489-1616
Practice Address - Fax:617-489-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-20
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADS899323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110102210AMedicaid
2141095OtherPK