Provider Demographics
NPI:1235836966
Name:WASYNCZUK, JACQUELINE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WASYNCZUK
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 1:400 WALNUT ST APT 4D
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3738
Mailing Address - Country:US
Mailing Address - Phone:765-413-7801
Mailing Address - Fax:
Practice Address - Street 1:901 WALNUT ST STE 901
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5224
Practice Address - Country:US
Practice Address - Phone:765-413-7801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP453872183500000X
IN26027130A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist