Provider Demographics
NPI:1194008565
Name:BEVILACQUA, KRYSTAL BRITTANY
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:BRITTANY
Last Name:BEVILACQUA
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 1:10 DAVOL SQ STE 400
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4752
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:
Practice Address - Street 1:10 DAVOL SQ STE 400
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4752
Practice Address - Country:US
Practice Address - Phone:401-421-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI5014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist