Provider Demographics
NPI:1720828189
Name:MOSALLAM, GRACE (RPH)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MOSALLAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HILLTOP ST
Mailing Address - Street 2:
Mailing Address - City:NORTH GRAFTON
Mailing Address - State:MA
Mailing Address - Zip Code:01536-1271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:264 W BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-1729
Practice Address - Country:US
Practice Address - Phone:781-492-4895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH997315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist