Provider Demographics
NPI:1427557461
Name:COSTANZO, STEVEN T
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:T
Last Name:COSTANZO
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 1:16 BRANNEGAN DR
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-2236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:266 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:CT
Practice Address - Zip Code:06413-2254
Practice Address - Country:US
Practice Address - Phone:860-669-6619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7793183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist