Provider Demographics
NPI:1689968240
Name:DAGOSTINO, GEORGE J JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:J
Last Name:DAGOSTINO
Suffix:JR
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 1:75 TUCKER HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-2512
Mailing Address - Country:US
Mailing Address - Phone:203-527-4117
Mailing Address - Fax:
Practice Address - Street 1:744 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-1906
Practice Address - Country:US
Practice Address - Phone:203-879-5853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist