Provider Demographics
NPI:1770892309
Name:MALATESTA, JOHN J (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:MALATESTA
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 1:101 MANSKER DR
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:MS
Mailing Address - Zip Code:39071-8700
Mailing Address - Country:US
Mailing Address - Phone:601-879-9682
Mailing Address - Fax:601-879-8722
Practice Address - Street 1:101 MANSKER DR
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:MS
Practice Address - Zip Code:39071-8700
Practice Address - Country:US
Practice Address - Phone:601-879-9682
Practice Address - Fax:601-879-8722
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-5552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist