Provider Demographics
NPI:1003411935
Name:ROMANELLO, KEIRA
Entity type:Individual
Prefix:
First Name:KEIRA
Middle Name:
Last Name:ROMANELLO
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 1:31 MATTAPAN ST
Mailing Address - Street 2:
Mailing Address - City:TEATICKET
Mailing Address - State:MA
Mailing Address - Zip Code:02536-6513
Mailing Address - Country:US
Mailing Address - Phone:201-705-4350
Mailing Address - Fax:
Practice Address - Street 1:105 DAVIS STRAITS
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-3909
Practice Address - Country:US
Practice Address - Phone:508-540-4307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH2397343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy