Healthcare Provider Details

I. General information

NPI: 1003962747
Provider Name (Legal Business Name): MRS. VICTORIA Y ANDINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 HARRISON AVE
BOSTON MA
02118-2371
US

IV. Provider business mailing address

47 RICHMERE RD
MATTAPAN MA
02126-3220
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-8130
  • Fax:
Mailing address:
  • Phone: 617-638-8130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number75
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: