Provider Demographics
NPI:1730366493
Name:WASTELL, MARC ALAN (RPH,MSDC)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:ALAN
Last Name:WASTELL
Suffix:
Gender:M
Credentials:RPH,MSDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-1404
Mailing Address - Country:US
Mailing Address - Phone:718-597-3000
Mailing Address - Fax:718-597-7842
Practice Address - Street 1:2112 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-1404
Practice Address - Country:US
Practice Address - Phone:718-597-3000
Practice Address - Fax:718-597-7842
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist