Provider Demographics
NPI:1437436888
Name:PESIRIDIS, JOANN
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:PESIRIDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOANN
Other - Middle Name:
Other - Last Name:PRIMBAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1101 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1101
Mailing Address - Country:US
Mailing Address - Phone:617-332-6880
Mailing Address - Fax:
Practice Address - Street 1:1101 BEACON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02461-1101
Practice Address - Country:US
Practice Address - Phone:617-332-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH27449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist