Provider Demographics
NPI:1871773242
Name:MASSOUD, MARY GAMIL (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GAMIL
Last Name:MASSOUD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5358
Mailing Address - Country:US
Mailing Address - Phone:607-272-6290
Mailing Address - Fax:
Practice Address - Street 1:615 S MEADOW ST
Practice Address - Street 2:RITE AID PHARMACY 4716
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5358
Practice Address - Country:US
Practice Address - Phone:607-272-6290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050241183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist