Provider Demographics
NPI:1962771923
Name:FAZZINI, ROBERT
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:FAZZINI
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 1:27 HAWTHORN DR
Mailing Address - Street 2:
Mailing Address - City:SUCCASUNNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07876-2115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 SOUTH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-9012
Practice Address - Country:US
Practice Address - Phone:973-538-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02086700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5642205Medicaid