Healthcare Provider Details

I. General information

NPI: 1629660485
Provider Name (Legal Business Name): ELAINE MARIE COSTICK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 CHAPMAN ST
PROVIDENCE RI
02905-5400
US

IV. Provider business mailing address

117 CHAPMAN ST
PROVIDENCE RI
02905-5400
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-9909
  • Fax: 401-444-4095
Mailing address:
  • Phone: 401-444-9909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberRPH06400
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH236085
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: