Provider Demographics
NPI:1649323981
Name:DEZINNO, ROGER C
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:C
Last Name:DEZINNO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 BRADLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-3914
Mailing Address - Country:US
Mailing Address - Phone:203-634-1042
Mailing Address - Fax:203-235-0244
Practice Address - Street 1:172 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-4104
Practice Address - Country:US
Practice Address - Phone:203-235-6305
Practice Address - Fax:203-235-0244
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2917183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2917OtherPHARMACY TEC