Provider Demographics
NPI:1275256505
Name:BACICA-FAHEY, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BACICA-FAHEY
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 1:1530 COWPATH RD
Mailing Address - Street 2:
Mailing Address - City:HATFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19440-3101
Mailing Address - Country:US
Mailing Address - Phone:215-361-2542
Mailing Address - Fax:215-361-2631
Practice Address - Street 1:1530 COWPATH RD
Practice Address - Street 2:
Practice Address - City:HATFIELD
Practice Address - State:PA
Practice Address - Zip Code:19440-3101
Practice Address - Country:US
Practice Address - Phone:215-361-2542
Practice Address - Fax:215-361-2631
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP038860L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA203622903OtherTAX ID
PA3988396OtherNABP#
PA1015538870015Medicaid
PAPP481736OtherSTATE LICENSE