MEDICARE: MARIO PENGILI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5351016301	MI

General Provider Information

NPI Number	:	1962161687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO PENGILI

Provider Business Mailing Address
First Line	:	49617 W CENTRAL PARK
Second Line	:
City	:	SHELBY TWP
State	:	MI
Zip	:	48317-6354
Country	:	US
Telephone Number	:	586-258-9842
Fax Number	:

Provider Business Practice Location Address
First Line	:	2115 25 MILE RD
Second Line	:
City	:	SHELBY TWP
State	:	MI
Zip	:	48316-1097
Country	:	US
Telephone Number	:	248-652-2227
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2021
Last Update Date	:	12/09/2021

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Directions to “ MARIO PENGILI ” Practice Location

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