Provider Demographics
NPI:1992478226
Name:MITA, ANDREW (RPH)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MITA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 PULLMAN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-3311
Mailing Address - Country:US
Mailing Address - Phone:508-854-8318
Mailing Address - Fax:
Practice Address - Street 1:72 PULLMAN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-3311
Practice Address - Country:US
Practice Address - Phone:508-854-8318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH27141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist