Provider Demographics
NPI:1114226248
Name:WISSUCHEK, RONALD JOEL (PHARMACISTS)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:JOEL
Last Name:WISSUCHEK
Suffix:
Gender:M
Credentials:PHARMACISTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-2198
Mailing Address - Country:US
Mailing Address - Phone:860-560-1881
Mailing Address - Fax:860-560-0614
Practice Address - Street 1:1291 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-2198
Practice Address - Country:US
Practice Address - Phone:860-560-1881
Practice Address - Fax:860-560-0614
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00062121835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0006212OtherCONNECTICUT STATE PHARMACIST LIC