Healthcare Provider Details

I. General information

NPI: 1548289051
Provider Name (Legal Business Name): PHILIP MICHAEL DUSSAULT JR. PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 CAUSEWAY ST
BOSTON MA
02114-2148
US

IV. Provider business mailing address

251 CAUSEWAY ST
BOSTON MA
02114-2148
US

V. Phone/Fax

Practice location:
  • Phone: 617-248-1290
  • Fax:
Mailing address:
  • Phone: 617-248-1470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number21111
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number21111
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: