Provider Demographics
NPI:1114474467
Name:SPIVACK, MITCHELL (RPH)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:SPIVACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7960 VERREE RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2531
Mailing Address - Country:US
Mailing Address - Phone:215-342-0100
Mailing Address - Fax:
Practice Address - Street 1:7960 VERREE RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2531
Practice Address - Country:US
Practice Address - Phone:215-342-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-03
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP032163L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist