Provider Demographics
NPI:1164105284
Name:BASTIANELLI, PAUL DANIEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DANIEL
Last Name:BASTIANELLI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3152 LYMAN ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-1147
Mailing Address - Country:US
Mailing Address - Phone:218-461-2892
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist