Provider Demographics
NPI:1417240672
Name:FASANO, RICHARD JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:FASANO
Suffix:JR
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 1:1545 PULASKI HWY
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-1303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1545 PULASKI HWY
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-1303
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2024-01-24
Deactivation Date:2020-03-20
Deactivation Code:
Reactivation Date:2024-01-23
Provider Licenses
StateLicense IDTaxonomies
MD20102183500000X
DEA1-0003927183500000X
PARP445465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist