Provider Demographics
NPI:1497045082
Name:MANCUSO, ALICE L (RPH)
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:L
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15851-1281
Mailing Address - Country:US
Mailing Address - Phone:814-653-8796
Mailing Address - Fax:
Practice Address - Street 1:201 W MAHONING ST
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-1918
Practice Address - Country:US
Practice Address - Phone:814-938-9161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP-033934-L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist