Healthcare Provider Details

I. General information

NPI: 1861006462
Provider Name (Legal Business Name): ADDISON CONCA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1737 ACUSHNET AVE
NEW BEDFORD MA
02746-2128
US

IV. Provider business mailing address

29 BROWNELL ST
WARREN RI
02885-1501
US

V. Phone/Fax

Practice location:
  • Phone: 508-984-4410
  • Fax:
Mailing address:
  • Phone: 845-401-0852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH05275
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH234915
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: