Provider Demographics
NPI:1699189118
Name:BORNACELLY, SANTANDER (B652758014569)
Entity Type:Individual
Prefix:
First Name:SANTANDER
Middle Name:
Last Name:BORNACELLY
Suffix:
Gender:M
Credentials:B652758014569
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13405 JOHN MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21795-1605
Mailing Address - Country:US
Mailing Address - Phone:301-739-7230
Mailing Address - Fax:301-733-1558
Practice Address - Street 1:580 WESEL BLVD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740
Practice Address - Country:US
Practice Address - Phone:301-739-7230
Practice Address - Fax:301-733-1558
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13789183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist