Provider Demographics
NPI:1699379594
Name:BELLIVEAU, LAURIE ANNE
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANNE
Last Name:BELLIVEAU
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 1:600 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01109-4104
Mailing Address - Country:US
Mailing Address - Phone:413-736-0351
Mailing Address - Fax:413-734-7037
Practice Address - Street 1:600 STATE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-4104
Practice Address - Country:US
Practice Address - Phone:413-736-0351
Practice Address - Fax:413-734-7037
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH25073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1972640829Medicaid
MA110087561VMedicaid