Provider Demographics
NPI:1144823006
Name:COSTANTINO, KENNYA D (PHARMD)
Entity type:Individual
Prefix:
First Name:KENNYA
Middle Name:D
Last Name:COSTANTINO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PEPPER HILL DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-3619
Mailing Address - Country:US
Mailing Address - Phone:857-204-0360
Mailing Address - Fax:
Practice Address - Street 1:1 MYSTIC VIEW RD
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-2428
Practice Address - Country:US
Practice Address - Phone:617-420-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH237446183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist