Provider Demographics
NPI:1861096059
Name:ETTI, MARIA
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:
Last Name:ETTI
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 1:928 RIVERDALE ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-4620
Mailing Address - Country:US
Mailing Address - Phone:413-733-6490
Mailing Address - Fax:413-733-6495
Practice Address - Street 1:928 RIVERDALE ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-4620
Practice Address - Country:US
Practice Address - Phone:413-733-6490
Practice Address - Fax:413-733-6495
Is Sole Proprietor?:No
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH21655183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist