Provider Demographics
NPI:1801257407
Name:VASSALLO, REGINA (PHARMD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:VASSALLO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 LUCAS LN APT 9
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-2537
Mailing Address - Country:US
Mailing Address - Phone:609-617-4257
Mailing Address - Fax:
Practice Address - Street 1:235 LUCAS LN APT 9
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-2537
Practice Address - Country:US
Practice Address - Phone:609-617-4257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03761100183500000X
PARP449892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP449892OtherPHARMACIST LICENSE
NJ28RI03761100OtherPHARMACIST LICENSE