Provider Demographics
NPI:1861070153
Name:DIBACCO, VINCENT (RPH)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:
Last Name:DIBACCO
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 1:1526 PACKER AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-5407
Mailing Address - Country:US
Mailing Address - Phone:215-906-6556
Mailing Address - Fax:
Practice Address - Street 1:1526 PACKER AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-5407
Practice Address - Country:US
Practice Address - Phone:267-909-9814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP034107L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist