Provider Demographics
NPI:1154651651
Name:WASILAK, JOHN STEPHAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:STEPHAN
Last Name:WASILAK
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 1:42 WINDING PATH DRIVE
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081
Mailing Address - Country:US
Mailing Address - Phone:904-460-2123
Mailing Address - Fax:
Practice Address - Street 1:42 WINDING PATH DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-0517
Practice Address - Country:US
Practice Address - Phone:904-460-2123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS26097183500000X
IN26060974A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist