Healthcare Provider Details

I. General information

NPI: 1194912667
Provider Name (Legal Business Name): EMILY SUE THIBEAULT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6106
US

IV. Provider business mailing address

18 INDIAN HILL RD
MEDFIELD MA
02052-2909
US

V. Phone/Fax

Practice location:
  • Phone: 617-264-3000
  • Fax:
Mailing address:
  • Phone: 920-810-9320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03227997
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP441819
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberMCS000084P
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPH240184
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: