Provider Demographics
NPI:1114280039
Name:CANZANESE, MARY F (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:F
Last Name:CANZANESE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:572 S HEILBRON DR
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-4500
Mailing Address - Country:US
Mailing Address - Phone:610-891-6796
Mailing Address - Fax:484-472-6562
Practice Address - Street 1:107 RUTGERS AVE STE 1
Practice Address - Street 2:
Practice Address - City:SWARTHMORE
Practice Address - State:PA
Practice Address - Zip Code:19081-1725
Practice Address - Country:US
Practice Address - Phone:484-472-6561
Practice Address - Fax:484-472-6562
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP039153L183500000X
PARP-039513L1835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No183500000XPharmacy Service ProvidersPharmacist