Provider Demographics
NPI:1881093136
Name:FANTOZZI, DAVID (RPH)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FANTOZZI
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 1:32653 WIDGEON RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN VIEW
Mailing Address - State:DE
Mailing Address - Zip Code:19970-8104
Mailing Address - Country:US
Mailing Address - Phone:301-509-0068
Mailing Address - Fax:
Practice Address - Street 1:39820 HICKMAN PLAZA RD
Practice Address - Street 2:
Practice Address - City:BETHANY BEACH
Practice Address - State:DE
Practice Address - Zip Code:19930-3760
Practice Address - Country:US
Practice Address - Phone:302-549-3548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0004194183500000X
MD10430183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist