Healthcare Provider Details

I. General information

NPI: 1063183366
Provider Name (Legal Business Name): GINO DESANTIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2021
Last Update Date: 09/26/2021
Certification Date: 09/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15400 W HIGH ST # 280
MIDDLEFIELD OH
44062-9212
US

IV. Provider business mailing address

15400 W HIGH ST # 280
MIDDLEFIELD OH
44062-9212
US

V. Phone/Fax

Practice location:
  • Phone: 440-632-5587
  • Fax: 440-632-0653
Mailing address:
  • Phone: 440-632-5587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03438965
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: