| Name: | FAIRLAWN PHARMACY, INCORPORATED |
| Jurisdiction: | Rhode Island |
| Entity type: | Domestic Profit Corporation |
| Status: | Revoked Entity |
| Date of Organization in Rhode Island: | 05 Mar 1958 (67 years ago) |
| Date of Dissolution: | 14 Sep 2012 (12 years ago) |
| Date of Status Change: | 14 Sep 2012 (12 years ago) |
| Identification Number: | 000005353 |
| ZIP code: | 02860 |
| County: | Providence County |
| Principal Address: | 582 SMITHFIELD AVENUE, PAWTUCKET, RI, 02860-1633, USA |
| Purpose: | FILLING PRESCRIPTIONS AND RETAIL, PHARMACY |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1366578775 | 2007-02-27 | 2007-09-12 | 582 SMITHFIELD AVE, PAWTUCKET, RI, 028601633, US | 582 SMITHFIELD AVE, PAWTUCKET, RI, 028601633, US | |||||||||||||||||||||||||||||||||||
|
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| Phone | +1 401-723-8070 |
Authorized person
| Name | BEDROS KOOSHERIAN |
| Role | PRESIDENT |
| Phone | 4017238070 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PHA00067 |
| State | RI |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | OTHER ID NUMBER |
| Number | 4101286 |
| Issuer | MEDICAID |
| Number | FP00779 |
| State | RI |
| Issuer | OTHER ID NUMBER-COMMERCIAL NUMBER |
| Number | 4101286 |
| Name | Role | Address |
|---|---|---|
| TRACEY M. KOOSHERIAN | Agent | 582 SMITHFIELD AVENUE, PAWTUCKET, RI, 02860, USA |
| Name | Role | Address |
|---|---|---|
| BEDROS KOOSHERIAN | PRESIDENT | 12 MEYERS COURT WARWICK, RI 02889 USA |
| Number | Name | File Date |
|---|---|---|
| 201297809770 | Revocation Certificate For Failure to File the Annual Report for the Year | 2012-09-14 |
| 201292953630 | Revocation Notice For Failure to File An Annual Report | 2012-05-23 |
| 201174594090 | Annual Report | 2011-02-07 |
| 201059680470 | Annual Report | 2010-02-26 |
| 200943023720 | Annual Report | 2009-02-23 |
| 200809756030 | Annual Report | 2008-03-13 |
Date of last update: 05 Oct 2024
Sources: Rhode Island Department of State
