Provider Demographics
NPI:1073738357
Name:WASICEK, KELLEY ANDRE (RPH)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANDRE
Last Name:WASICEK
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 1:725 THOMPSON RUN RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15237-3970
Mailing Address - Country:US
Mailing Address - Phone:412-492-7054
Mailing Address - Fax:
Practice Address - Street 1:200 LOTHROP ST
Practice Address - Street 2:SUITE G-119
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2536
Practice Address - Country:US
Practice Address - Phone:412-647-0541
Practice Address - Fax:412-647-9694
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP-034040-L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist