Provider Demographics
NPI:1528405040
Name:DIMOVA, ANTONINA
Entity Type:Individual
Prefix:
First Name:ANTONINA
Middle Name:
Last Name:DIMOVA
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 1:303 MAPLE ST APT B2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-1959
Mailing Address - Country:US
Mailing Address - Phone:413-205-7957
Mailing Address - Fax:
Practice Address - Street 1:303 MAPLE ST APT B2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1959
Practice Address - Country:US
Practice Address - Phone:413-205-7957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH234492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist