Provider Demographics
NPI:1154927093
Name:MASCITELLI, MARK (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MASCITELLI
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 1:816 OLIVE GLEN CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-6801
Mailing Address - Country:US
Mailing Address - Phone:772-215-5909
Mailing Address - Fax:
Practice Address - Street 1:2700 YULUPA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-8577
Practice Address - Country:US
Practice Address - Phone:707-545-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH83816183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist