Provider Demographics
NPI:1881971323
Name:MASSANISSO, SALVATORE J (RPH)
Entity type:Individual
Prefix:MR
First Name:SALVATORE
Middle Name:J
Last Name:MASSANISSO
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 1:2 N LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2001
Mailing Address - Country:US
Mailing Address - Phone:708-352-3116
Mailing Address - Fax:708-352-2115
Practice Address - Street 1:2 N LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2001
Practice Address - Country:US
Practice Address - Phone:708-352-3116
Practice Address - Fax:708-352-2115
Is Sole Proprietor?:No
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.030820183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist