Provider Demographics
NPI:1003267378
Name:SUGENO, MASATO CHARLES (PHARMD)
Entity Type:Individual
Prefix:
First Name:MASATO
Middle Name:CHARLES
Last Name:SUGENO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 S 46TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-3826
Mailing Address - Country:US
Mailing Address - Phone:609-902-1231
Mailing Address - Fax:
Practice Address - Street 1:5501 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-5607
Practice Address - Country:US
Practice Address - Phone:215-729-3912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP449589183500000X
DEA1-0004684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist