Provider Demographics
NPI:1295873750
Name:FORNATARO, MICHAEL VITO (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:VITO
Last Name:FORNATARO
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 1:708 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-4137
Mailing Address - Country:US
Mailing Address - Phone:724-658-4557
Mailing Address - Fax:724-658-4547
Practice Address - Street 1:708 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101-4137
Practice Address - Country:US
Practice Address - Phone:724-658-4557
Practice Address - Fax:724-658-4547
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP036614L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3937476OtherNABP
PA0019495420001Medicaid
PA3937476OtherNABP