Provider Demographics
NPI:1629734439
Name:DRISCOLL, STEPHEN MICHAEL
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:DRISCOLL
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 1:97 OAKLAND ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-1930
Mailing Address - Country:US
Mailing Address - Phone:339-987-0985
Mailing Address - Fax:
Practice Address - Street 1:97 OAKLAND ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-1930
Practice Address - Country:US
Practice Address - Phone:339-987-0985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA16539OtherLICENSE