Provider Demographics
NPI:1871914929
Name:DISTEFANO, CONSTANTINO
Entity type:Individual
Prefix:
First Name:CONSTANTINO
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-3607
Mailing Address - Country:US
Mailing Address - Phone:203-845-0616
Mailing Address - Fax:
Practice Address - Street 1:189 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-3607
Practice Address - Country:US
Practice Address - Phone:203-845-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5945183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist