Provider Demographics
NPI:1457783557
Name:IKONOMI, ERINDA
Entity Type:Individual
Prefix:
First Name:ERINDA
Middle Name:
Last Name:IKONOMI
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 1:24 EL CANEY RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01603-1005
Mailing Address - Country:US
Mailing Address - Phone:508-410-2126
Mailing Address - Fax:
Practice Address - Street 1:393 CHANDLER ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01602-3329
Practice Address - Country:US
Practice Address - Phone:508-754-5348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH234780183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist