Provider Demographics
NPI:1952787434
Name:ANCONA, CARISSA
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:ANCONA
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 1:30 EVANS LN
Mailing Address - Street 2:
Mailing Address - City:HOPE VALLEY
Mailing Address - State:RI
Mailing Address - Zip Code:02832-2313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 BROAD ST
Practice Address - Street 2:SUITE 6
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1362
Practice Address - Country:US
Practice Address - Phone:401-868-9070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH05471183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist