Provider Demographics
NPI:1689884249
Name:FUSCO, THEODORE VICTOR III (RPH)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:VICTOR
Last Name:FUSCO
Suffix:III
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 N HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2024
Mailing Address - Country:US
Mailing Address - Phone:630-279-0317
Mailing Address - Fax:
Practice Address - Street 1:920 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2240
Practice Address - Country:US
Practice Address - Phone:847-623-7066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2015-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051287055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist