Provider Demographics
NPI:1164027801
Name:DECAROLIS, GINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:DECAROLIS
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 1:411 MANCHESTER AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3821
Mailing Address - Country:US
Mailing Address - Phone:484-684-0249
Mailing Address - Fax:
Practice Address - Street 1:1306 MACDADE BLVD
Practice Address - Street 2:
Practice Address - City:WOODLYN
Practice Address - State:PA
Practice Address - Zip Code:19094-1599
Practice Address - Country:US
Practice Address - Phone:610-521-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0005023183500000X
PARP450954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist