Provider Demographics
NPI:1982046470
Name:MONGILLO, MARK (PHARMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MONGILLO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 BLACK RIVER BLVD N
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2425
Mailing Address - Country:US
Mailing Address - Phone:315-336-8890
Mailing Address - Fax:
Practice Address - Street 1:1727 BLACK RIVER BLVD N
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2425
Practice Address - Country:US
Practice Address - Phone:315-336-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP447842183500000X
NY058233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist