Provider Demographics
NPI:1346845294
Name:CHRISTIANSON, MIMI B (RPH)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:B
Last Name:CHRISTIANSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 LOWELL ST
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-7476
Mailing Address - Country:US
Mailing Address - Phone:978-535-2062
Mailing Address - Fax:978-535-7653
Practice Address - Street 1:535 LOWELL ST
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-7476
Practice Address - Country:US
Practice Address - Phone:978-535-2062
Practice Address - Fax:978-535-7653
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH21695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist