Provider Demographics
NPI:1093398000
Name:MASSULLO, PAM (MS, PHARMD, PHD)
Entity Type:Individual
Prefix:DR
First Name:PAM
Middle Name:
Last Name:MASSULLO
Suffix:
Gender:F
Credentials:MS, PHARMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6617 COVINGTON CV
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8163
Mailing Address - Country:US
Mailing Address - Phone:161-459-8944
Mailing Address - Fax:
Practice Address - Street 1:6617 COVINGTON CV
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-8163
Practice Address - Country:US
Practice Address - Phone:161-459-8944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03331252183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist