Provider Demographics
NPI:1013788223
Name:MOM, ALICA
Entity Type:Individual
Prefix:
First Name:ALICA
Middle Name:
Last Name:MOM
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 1:13 VARNUM ST
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01832-5216
Mailing Address - Country:US
Mailing Address - Phone:781-691-1028
Mailing Address - Fax:
Practice Address - Street 1:2 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-7911
Practice Address - Country:US
Practice Address - Phone:978-977-7744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPT101225183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician