Provider Demographics
NPI:1255953097
Name:SIDIE, RICHARD PAUL
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:PAUL
Last Name:SIDIE
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 1:128 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1537
Mailing Address - Country:US
Mailing Address - Phone:978-682-5122
Mailing Address - Fax:978-794-3061
Practice Address - Street 1:128 PARKER ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1537
Practice Address - Country:US
Practice Address - Phone:978-682-5122
Practice Address - Fax:978-794-3061
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist