Provider Demographics
NPI:1114150802
Name:MASCALO, CORY JAMES (RPH)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:JAMES
Last Name:MASCALO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 COLLINS RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-3893
Mailing Address - Country:US
Mailing Address - Phone:860-589-5587
Mailing Address - Fax:860-584-8574
Practice Address - Street 1:25 COLLINS RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-3893
Practice Address - Country:US
Practice Address - Phone:860-589-5587
Practice Address - Fax:860-584-8574
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist