Provider Demographics
NPI:1730307166
Name:BACON, MARC (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:
Last Name:BACON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BROOKDALE LN
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-3437
Mailing Address - Country:US
Mailing Address - Phone:978-443-4495
Mailing Address - Fax:
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:NEW ENGLAND BAPTIST HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-754-5787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21311183500000X, 1835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support