Provider Demographics
NPI:1063183366
Name:DESANTIS, GINO
Entity type:Individual
Prefix:
First Name:GINO
Middle Name:
Last Name:DESANTIS
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 1:15400 W HIGH ST # 280
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44062-9212
Mailing Address - Country:US
Mailing Address - Phone:440-632-5587
Mailing Address - Fax:
Practice Address - Street 1:15400 W HIGH ST # 280
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:OH
Practice Address - Zip Code:44062-9212
Practice Address - Country:US
Practice Address - Phone:440-632-5587
Practice Address - Fax:440-632-0653
Is Sole Proprietor?:No
Enumeration Date:2021-09-26
Last Update Date:2021-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03438965183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist