Provider Demographics
NPI:1114987542
Name:KIETLINSKI, WANDA (RPH)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:KIETLINSKI
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 1:260 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-3522
Mailing Address - Country:US
Mailing Address - Phone:973-324-1000
Mailing Address - Fax:973-324-2121
Practice Address - Street 1:260 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-3522
Practice Address - Country:US
Practice Address - Phone:973-324-1000
Practice Address - Fax:973-324-2121
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2022-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02156000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3387208Medicaid
NJ024332Medicare PIN
U74011Medicare UPIN