Provider Demographics
NPI:1760936728
Name:IACANO, MARIO MICHAEL (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:MICHAEL
Last Name:IACANO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 34TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:OH
Mailing Address - Zip Code:43906-1538
Mailing Address - Country:US
Mailing Address - Phone:740-676-5621
Mailing Address - Fax:
Practice Address - Street 1:428 34TH ST
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:OH
Practice Address - Zip Code:43906-1538
Practice Address - Country:US
Practice Address - Phone:740-676-5621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03136177183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist