Provider Demographics
NPI:1285024778
Name:ROACH, KERRI ANN
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:ANN
Last Name:ROACH
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 1:128 ENDICOTT AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-4158
Mailing Address - Country:US
Mailing Address - Phone:617-347-7126
Mailing Address - Fax:
Practice Address - Street 1:36 FURLONG DR
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-4006
Practice Address - Country:US
Practice Address - Phone:781-922-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPI157302183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician