Provider Demographics
NPI:1376894030
Name:BETANCOURT, SOFIA (BS, PHARMD)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:BS, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 WASHINGTON ST
Mailing Address - Street 2:APT 9
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1831
Mailing Address - Country:US
Mailing Address - Phone:954-415-0503
Mailing Address - Fax:
Practice Address - Street 1:972 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-4701
Practice Address - Country:US
Practice Address - Phone:617-327-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH234094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist