Provider Demographics
NPI:1124412135
Name:WISNIEWSKI, JUSTINE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-2074
Mailing Address - Country:US
Mailing Address - Phone:336-751-2141
Mailing Address - Fax:336-751-7974
Practice Address - Street 1:495 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2074
Practice Address - Country:US
Practice Address - Phone:336-751-2141
Practice Address - Fax:336-751-7974
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21511183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0305086Medicaid
NC0132880001Medicare NSC