Provider Demographics
NPI:1093310070
Name:ROSTOM, MIRA (DR)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:ROSTOM
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1705
Mailing Address - Country:US
Mailing Address - Phone:774-314-5585
Mailing Address - Fax:
Practice Address - Street 1:9 NELSON ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-2131
Practice Address - Country:US
Practice Address - Phone:978-840-8343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH239106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist