Provider Demographics
NPI:1093311623
Name:MONSALVE-NICHOLLS, SALOME
Entity Type:Individual
Prefix:
First Name:SALOME
Middle Name:
Last Name:MONSALVE-NICHOLLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 FELLSWAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4925
Mailing Address - Country:US
Mailing Address - Phone:781-391-2668
Mailing Address - Fax:
Practice Address - Street 1:590 FELLSWAY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4925
Practice Address - Country:US
Practice Address - Phone:781-391-2668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH238549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty