Provider Demographics
NPI:1194997221
Name:MUSTICO, STEPHANIE BLANCHE (PHARMD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BLANCHE
Last Name:MUSTICO
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 1:1500 BROOKS AVE
Mailing Address - Street 2:ATTN: PHARMACY MANAGER
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-3512
Mailing Address - Country:US
Mailing Address - Phone:585-239-2020
Mailing Address - Fax:585-239-2015
Practice Address - Street 1:1100 CLEMENS CENTER PKWY
Practice Address - Street 2:ATTN: PHARMACY MANAGER
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-1563
Practice Address - Country:US
Practice Address - Phone:607-737-5090
Practice Address - Fax:637-737-5067
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY051079OtherPHARMACIST LICENSE