Provider Demographics
NPI:1538215231
Name:KIMMY PHARMACY
Entity type:Organization
Organization Name:KIMMY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:617-288-8199
Mailing Address - Street 1:1435 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-2915
Mailing Address - Country:US
Mailing Address - Phone:617-288-8199
Mailing Address - Fax:617-288-8191
Practice Address - Street 1:1435 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-2915
Practice Address - Country:US
Practice Address - Phone:617-288-8199
Practice Address - Fax:617-288-8191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1888332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0437239Medicaid
5561740001Medicare ID - Type Unspecified