Provider Demographics
NPI:1235732819
Name:PHELAN, KEIRSTEN ROCHELLE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:KEIRSTEN
Middle Name:ROCHELLE
Last Name:PHELAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5292
Mailing Address - Country:US
Mailing Address - Phone:617-236-8538
Mailing Address - Fax:617-236-4267
Practice Address - Street 1:285 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5292
Practice Address - Country:US
Practice Address - Phone:617-236-8538
Practice Address - Fax:617-236-4267
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA26510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist