Provider Demographics
NPI:1326595026
Name:RYAN, KEVIN
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:RYAN
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 1:55 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-2009
Mailing Address - Country:US
Mailing Address - Phone:401-855-1450
Mailing Address - Fax:
Practice Address - Street 1:100 POWDERMILL RD
Practice Address - Street 2:RITE AID PHARMACY
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-5932
Practice Address - Country:US
Practice Address - Phone:978-897-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH234702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist