Provider Demographics
NPI:1417511718
Name:MASTROIANNI, MICHAEL A (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:MASTROIANNI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STOLLS PHARMACY INC
Mailing Address - Street 2:185 GROVE ST
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710
Mailing Address - Country:US
Mailing Address - Phone:203-575-0199
Mailing Address - Fax:203-575-0515
Practice Address - Street 1:STOLLS PHARMACY INC
Practice Address - Street 2:185 GROVE ST
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710
Practice Address - Country:US
Practice Address - Phone:203-575-0199
Practice Address - Fax:203-575-0515
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0007580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004083234Medicaid
CT0139070001OtherMEDICARE