Provider Demographics
NPI:1699818195
Name:GRACIEUX, MEGRACIE MT (PH TECH)
Entity Type:Individual
Prefix:
First Name:MEGRACIE
Middle Name:MT
Last Name:GRACIEUX
Suffix:
Gender:F
Credentials:PH TECH
Other - Prefix:
Other - First Name:MERLANGE
Other - Middle Name:MT
Other - Last Name:GRACIEUX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PH TECH
Mailing Address - Street 1:34 PLEASANTDALE RD
Mailing Address - Street 2:MERLANGE GRACIEUX
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-6204
Mailing Address - Country:US
Mailing Address - Phone:617-325-3256
Mailing Address - Fax:
Practice Address - Street 1:850 HARRISON AVENUE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-7653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1824183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician