Provider Demographics
NPI:1972783629
Name:MASTROIANNI, JAMES A (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:MASTROIANNI
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 1:21 FINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:13502-1237
Mailing Address - Country:US
Mailing Address - Phone:315-734-9425
Mailing Address - Fax:
Practice Address - Street 1:9225 RIVER ROAD
Practice Address - Street 2:
Practice Address - City:MARCY
Practice Address - State:NY
Practice Address - Zip Code:13403
Practice Address - Country:US
Practice Address - Phone:157-687-4703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-10
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01246226Medicaid