Provider Demographics
NPI:1740552835
Name:DEICICCHI, DAVID (PHARMD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DEICICCHI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4339
Mailing Address - Country:US
Mailing Address - Phone:617-264-5872
Mailing Address - Fax:
Practice Address - Street 1:41 AVENUE LOUIS PASTEUR STE 216
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5727
Practice Address - Country:US
Practice Address - Phone:617-264-5872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH232796183500000X, 1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMD1123277POtherMCSR