Healthcare Provider Details

I. General information

NPI: 1245552264
Provider Name (Legal Business Name): MARK MAIOLO RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2010
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 E MAIN ST
MALONE NY
12953-2126
US

IV. Provider business mailing address

485 E MAIN ST
MALONE NY
12953-2126
US

V. Phone/Fax

Practice location:
  • Phone: 518-483-3371
  • Fax: 518-483-4493
Mailing address:
  • Phone: 518-483-3371
  • Fax: 518-483-4493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number045368
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: