Provider Demographics
NPI:1770170094
Name:RODRIGUES, ELVISH
Entity type:Individual
Prefix:
First Name:ELVISH
Middle Name:
Last Name:RODRIGUES
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 1:540 SQUIRE RD
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1863
Mailing Address - Country:US
Mailing Address - Phone:781-289-6879
Mailing Address - Fax:
Practice Address - Street 1:540 SQUIRE RD
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-1863
Practice Address - Country:US
Practice Address - Phone:781-289-6879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH233658183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist