Provider Demographics
NPI:1861110447
Name:SIDAROS, SUZY S
Entity type:Individual
Prefix:
First Name:SUZY
Middle Name:S
Last Name:SIDAROS
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 1:159 MARSH RD
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03076-3355
Mailing Address - Country:US
Mailing Address - Phone:978-360-1629
Mailing Address - Fax:
Practice Address - Street 1:25 WOOD ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-1518
Practice Address - Country:US
Practice Address - Phone:978-458-4621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH240778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist