Provider Demographics
NPI:1770872392
Name:MUCCIOLO, SARAH J
Entity type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:J
Last Name:MUCCIOLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 S KEYSER AVE
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1148
Mailing Address - Country:US
Mailing Address - Phone:570-457-4069
Mailing Address - Fax:
Practice Address - Street 1:191 S KEYSER AVE
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1148
Practice Address - Country:US
Practice Address - Phone:570-457-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP036880L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist