Provider Demographics
NPI:1275000424
Name:WIELGOPOLSKI, KEN (RPH)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:WIELGOPOLSKI
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 1:1862 STEEL ST
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:PA
Mailing Address - Zip Code:18603-2548
Mailing Address - Country:US
Mailing Address - Phone:570-204-0464
Mailing Address - Fax:
Practice Address - Street 1:1015 N VINE ST
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:PA
Practice Address - Zip Code:18603-2025
Practice Address - Country:US
Practice Address - Phone:570-802-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP040286L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist