Healthcare Provider Details

I. General information

NPI: 1912270356
Provider Name (Legal Business Name): MR. ANTHONY JAMES YACULLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 GINESI DR
MORGANVILLE NJ
07751-1235
US

IV. Provider business mailing address

1212 BAY AVE
BAY HEAD NJ
08742-4016
US

V. Phone/Fax

Practice location:
  • Phone: 888-809-4772
  • Fax:
Mailing address:
  • Phone: 732-892-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRI00024983
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: