Provider Demographics
NPI:1629731229
Name:COSTELLO, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:COSTELLO
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 1:162 E DERRY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03036-4319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 E DERRY RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NH
Practice Address - Zip Code:03036-4319
Practice Address - Country:US
Practice Address - Phone:603-716-0533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH01248183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist