Provider Demographics
NPI:1184347692
Name:FAJE, TRICIA (PHD)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:FAJE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-4619
Mailing Address - Country:US
Mailing Address - Phone:617-277-6080
Mailing Address - Fax:617-277-4951
Practice Address - Street 1:214 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-4619
Practice Address - Country:US
Practice Address - Phone:617-277-6080
Practice Address - Fax:617-277-4951
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH240643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist