Provider Demographics
NPI:1871756346
Name:COSTELLO, CHERYL (RPH)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:COSTELLO
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 1:1703B ROUTE 5 N
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:VT
Mailing Address - Zip Code:05055-9494
Mailing Address - Country:US
Mailing Address - Phone:802-649-1480
Mailing Address - Fax:
Practice Address - Street 1:1703B ROUTE 5 N
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:VT
Practice Address - Zip Code:05055-9494
Practice Address - Country:US
Practice Address - Phone:802-649-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-05
Last Update Date:2008-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist