Provider Demographics
NPI:1437337615
Name:MASCARELLI, RAYMOND JOHN
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:JOHN
Last Name:MASCARELLI
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 1:5801 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4841
Mailing Address - Country:US
Mailing Address - Phone:631-567-6969
Mailing Address - Fax:
Practice Address - Street 1:5801 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4841
Practice Address - Country:US
Practice Address - Phone:631-567-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-10
Last Update Date:2008-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027518-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00513126Medicaid