Provider Demographics
NPI:1811577398
Name:SHAKERI, MOHAMMAD
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:SHAKERI
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 1:710 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1504
Mailing Address - Country:US
Mailing Address - Phone:617-269-5788
Mailing Address - Fax:
Practice Address - Street 1:710 E BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-1504
Practice Address - Country:US
Practice Address - Phone:617-269-5788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH19962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist