Healthcare Provider Details

I. General information

NPI: 1215872155
Provider Name (Legal Business Name): IVAN FERNANDEZ
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1298 COMMONWEALTH AVE APT 4
BOSTON MA
02134-4019
US

IV. Provider business mailing address

1298 COMMONWEALTH AVE APT 4
BOSTON MA
02134-4019
US

V. Phone/Fax

Practice location:
  • Phone: 401-430-0513
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH1002948
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: