Provider Demographics
NPI:1265823777
Name:PALLACOVITCH, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:PALLACOVITCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 WOODBURY GLASSBORO RD
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-3733
Mailing Address - Country:US
Mailing Address - Phone:856-415-2381
Mailing Address - Fax:856-415-2381
Practice Address - Street 1:675 WOODBURY GLASSBORO RD
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-3733
Practice Address - Country:US
Practice Address - Phone:856-415-2381
Practice Address - Fax:856-415-2391
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RW02131700183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician