Provider Demographics
NPI:1598360117
Name:METALLIDIS, MARIE-THERESE
Entity Type:Individual
Prefix:
First Name:MARIE-THERESE
Middle Name:
Last Name:METALLIDIS
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 1:51 SAUNDERS ST
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-1929
Mailing Address - Country:US
Mailing Address - Phone:617-835-4606
Mailing Address - Fax:
Practice Address - Street 1:590 FELLSWAY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4925
Practice Address - Country:US
Practice Address - Phone:781-391-2668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist