Provider Demographics
NPI:1164025763
Name:YELISAVETSKIY, ALEXANDER (PHARMD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:YELISAVETSKIY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:YELISAV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:481 ANGELL ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4407
Mailing Address - Country:US
Mailing Address - Phone:401-521-4340
Mailing Address - Fax:401-273-4217
Practice Address - Street 1:481 ANGELL ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4407
Practice Address - Country:US
Practice Address - Phone:401-521-4340
Practice Address - Fax:401-273-4217
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA26451183500000X
RI04249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist