Provider Demographics
NPI:1992275754
Name:COSTA, JUSTIN M
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:COSTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 BROWNELL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-2717
Mailing Address - Country:US
Mailing Address - Phone:508-410-1451
Mailing Address - Fax:
Practice Address - Street 1:677 MAIN RD
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878-1352
Practice Address - Country:US
Practice Address - Phone:401-624-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH238590183500000X
RIRPH05959183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPH238590OtherMA BOARD OF PHARMACY
RIRPH05959OtherRI BOARD OF PHARMACY