Provider Demographics
NPI:1750043832
Name:HENRIQUEZ, ANDY HAMILTON
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:HAMILTON
Last Name:HENRIQUEZ
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 1:52 WOODLAWN ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5040
Mailing Address - Country:US
Mailing Address - Phone:617-899-3670
Mailing Address - Fax:
Practice Address - Street 1:516 MAIN ST # 522
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3880
Practice Address - Country:US
Practice Address - Phone:781-665-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH240450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty