Provider Demographics
NPI:1487973616
Name:DETINO, MARCELLO
Entity type:Individual
Prefix:MR
First Name:MARCELLO
Middle Name:
Last Name:DETINO
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 1:3195 RANDOLPH PL
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-1276
Mailing Address - Country:US
Mailing Address - Phone:718-918-1240
Mailing Address - Fax:
Practice Address - Street 1:1543 OHM AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-1111
Practice Address - Country:US
Practice Address - Phone:718-918-1240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039751183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist