Provider Demographics
NPI:1841573185
Name:DESTASIO, VINCENT ALBERT JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:ALBERT
Last Name:DESTASIO
Suffix:JR
Gender:M
Credentials:RPH
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Mailing Address - Street 1:6111 HICKORY FLAT HWY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-7253
Mailing Address - Country:US
Mailing Address - Phone:770-479-7039
Mailing Address - Fax:770-479-5923
Practice Address - Street 1:6111 HICKORY FLAT HWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-7253
Practice Address - Country:US
Practice Address - Phone:770-479-7039
Practice Address - Fax:770-479-5923
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARPH023608183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist