Provider Demographics
NPI:1528596038
Name:SCIULLO, ANTHONY (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:SCIULLO
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4049
Mailing Address - Country:US
Mailing Address - Phone:860-647-0325
Mailing Address - Fax:
Practice Address - Street 1:286 BROAD ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4049
Practice Address - Country:US
Practice Address - Phone:860-647-0325
Practice Address - Fax:860-647-0325
Is Sole Proprietor?:No
Enumeration Date:2017-05-28
Last Update Date:2017-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004122438Medicaid