Provider Demographics
NPI:1396340378
Name:LEVESQUE-DEGRAZIA, SUSAN HELEN (RPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:HELEN
Last Name:LEVESQUE-DEGRAZIA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 METACOM AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-5188
Mailing Address - Country:US
Mailing Address - Phone:401-253-2050
Mailing Address - Fax:401-254-7413
Practice Address - Street 1:400 METACOM AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-5188
Practice Address - Country:US
Practice Address - Phone:401-253-2050
Practice Address - Fax:401-254-7413
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
MA19353183500000X
RI3019183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1407950207OtherCVS PHARMACY 645