Provider Demographics
NPI:1033391198
Name:WEJCHERT, MARK P
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:WEJCHERT
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 1:335 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2418
Mailing Address - Country:US
Mailing Address - Phone:631-928-6800
Mailing Address - Fax:631-928-8644
Practice Address - Street 1:335 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2418
Practice Address - Country:US
Practice Address - Phone:631-928-6800
Practice Address - Fax:631-928-8644
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030630183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00351111Medicaid