Provider Demographics
NPI:1275167918
Name:VASCONI, MARIO LOUIS
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:LOUIS
Last Name:VASCONI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-1904
Mailing Address - Country:US
Mailing Address - Phone:707-963-1447
Mailing Address - Fax:
Practice Address - Street 1:1381 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-1904
Practice Address - Country:US
Practice Address - Phone:707-963-1447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA135790Medicaid