Provider Demographics
NPI:1043784515
Name:ILCEWICZ, HALEY NICOLE
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:NICOLE
Last Name:ILCEWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8045
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-8045
Mailing Address - Country:US
Mailing Address - Phone:304-598-4148
Mailing Address - Fax:304-598-4073
Practice Address - Street 1:1 MEDICAL CENTER DR DEPT OF
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-1200
Practice Address - Country:US
Practice Address - Phone:304-598-4148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0010530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRP0010530OtherPHARMACIST