Provider Demographics
NPI:1710551056
Name:MUCCINO, TIM M
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:M
Last Name:MUCCINO
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 1:2618- A MEMORIAL BLD
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425
Mailing Address - Country:US
Mailing Address - Phone:724-628-7500
Mailing Address - Fax:724-628-7550
Practice Address - Street 1:2618- A MEMORIAL BLD
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425
Practice Address - Country:US
Practice Address - Phone:724-628-7500
Practice Address - Fax:724-628-7550
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP437667183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016537570001Medicaid