Provider Demographics
NPI:1952638934
Name:MASTROMONICA, MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MASTROMONICA
Suffix:
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 1:999 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8990
Mailing Address - Country:US
Mailing Address - Phone:425-313-2892
Mailing Address - Fax:425-313-6595
Practice Address - Street 1:999 LAKE DR
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8990
Practice Address - Country:US
Practice Address - Phone:425-313-2892
Practice Address - Fax:425-313-6595
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ14748183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist