Provider Demographics
NPI:1811365885
Name:BAKOLAS, DIMITRIOS SOTIRIOS
Entity Type:Individual
Prefix:
First Name:DIMITRIOS
Middle Name:SOTIRIOS
Last Name:BAKOLAS
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 1:2150 PROVIDENCE HWY
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-2525
Mailing Address - Country:US
Mailing Address - Phone:617-325-0017
Mailing Address - Fax:
Practice Address - Street 1:825 MORTON ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-1850
Practice Address - Country:US
Practice Address - Phone:617-298-3114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH236236183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist