Provider Demographics
NPI:1073898300
Name:MONTEFUSCO, PETER MICHAEL
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:MICHAEL
Last Name:MONTEFUSCO
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 1:93 CANDLEWICK DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-5706
Mailing Address - Country:US
Mailing Address - Phone:302-697-8085
Mailing Address - Fax:
Practice Address - Street 1:1001 FORREST AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3306
Practice Address - Country:US
Practice Address - Phone:302-678-9820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0001845183500000X
PARP029092L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist