Provider Demographics
NPI:1386656064
Name:FUSCO, ROBERT SR
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:FUSCO
Suffix:SR
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 1:514 OLD TOLL RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-1822
Mailing Address - Country:US
Mailing Address - Phone:207-421-3577
Mailing Address - Fax:
Practice Address - Street 1:514 OLD TOLL RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-1822
Practice Address - Country:US
Practice Address - Phone:207-421-3577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY.2067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPSY.2067OtherPHARMACY LICENSE