Provider Demographics
NPI:1124388533
Name:GALLO, MARISSA LYNN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:LYNN
Last Name:GALLO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8935 42ND CT
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-5302
Mailing Address - Country:US
Mailing Address - Phone:262-705-7976
Mailing Address - Fax:
Practice Address - Street 1:1920 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-4614
Practice Address - Country:US
Practice Address - Phone:262-633-4948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16476-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist