Provider Demographics
NPI:1548585839
Name:MASSARO, VINCENT PATRICK
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:PATRICK
Last Name:MASSARO
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 1:3781 MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1557
Mailing Address - Country:US
Mailing Address - Phone:315-487-5775
Mailing Address - Fax:
Practice Address - Street 1:3781 MILTON AVE
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1557
Practice Address - Country:US
Practice Address - Phone:315-487-5775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00905748Medicaid