Provider Demographics
NPI:1104167576
Name:GUASTELLA, ROSS PHILLIP (RPH)
Entity type:Individual
Prefix:MR
First Name:ROSS
Middle Name:PHILLIP
Last Name:GUASTELLA
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 1:142 VICTORIA PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-5502
Mailing Address - Country:US
Mailing Address - Phone:901-341-3603
Mailing Address - Fax:
Practice Address - Street 1:4300 NEW GETWELL RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-6801
Practice Address - Country:US
Practice Address - Phone:901-341-3606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-12757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist