Provider Demographics
NPI:1194277707
Name:MALLESKE, GINAMARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:GINAMARIE
Middle Name:
Last Name:MALLESKE
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 1:5501 MAHONING AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2316
Mailing Address - Country:US
Mailing Address - Phone:330-792-4785
Mailing Address - Fax:
Practice Address - Street 1:5501 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2316
Practice Address - Country:US
Practice Address - Phone:330-792-4785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-30
Last Update Date:2016-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03236460183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist