Provider Demographics
NPI:1184395063
Name:BAUTISTA, ALICIA (PHARMD)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MULBERRY ST APT 4
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743-2541
Mailing Address - Country:US
Mailing Address - Phone:518-932-9977
Mailing Address - Fax:
Practice Address - Street 1:52 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-1308
Practice Address - Country:US
Practice Address - Phone:802-674-2334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0134578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist