Provider Demographics
NPI:1548784259
Name:MARSELLA, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MARSELLA
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 1:220 ROUTE 12
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3414
Mailing Address - Country:US
Mailing Address - Phone:860-445-8807
Mailing Address - Fax:860-446-1091
Practice Address - Street 1:220 ROUTE 12
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3414
Practice Address - Country:US
Practice Address - Phone:860-445-8807
Practice Address - Fax:860-445-8807
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist