Provider Demographics
NPI:1558795708
Name:BARUA, PRITAM
Entity Type:Individual
Prefix:
First Name:PRITAM
Middle Name:
Last Name:BARUA
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 1:299 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-1933
Mailing Address - Country:US
Mailing Address - Phone:617-628-1010
Mailing Address - Fax:617-628-1564
Practice Address - Street 1:299 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-1933
Practice Address - Country:US
Practice Address - Phone:617-628-1010
Practice Address - Fax:617-628-1564
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH234884183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist