Provider Demographics
NPI:1194321281
Name:KISUBIKA, RECHEAL NANTEZA
Entity type:Individual
Prefix:
First Name:RECHEAL
Middle Name:NANTEZA
Last Name:KISUBIKA
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 1:14 AUDUBON RD APT 541
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-1342
Mailing Address - Country:US
Mailing Address - Phone:781-296-1016
Mailing Address - Fax:
Practice Address - Street 1:969 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1609
Practice Address - Country:US
Practice Address - Phone:781-340-5620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH2392551835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist