Provider Demographics
NPI:1235489311
Name:KINAN, STEPHEN RONALD
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RONALD
Last Name:KINAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-2535
Mailing Address - Country:US
Mailing Address - Phone:617-436-3400
Mailing Address - Fax:617-436-2243
Practice Address - Street 1:1735 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-2535
Practice Address - Country:US
Practice Address - Phone:617-436-3400
Practice Address - Fax:617-436-2243
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20994183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist