Provider Demographics
NPI:1316593353
Name:PENVOSE, SELINA RAE
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:RAE
Last Name:PENVOSE
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 1:305 MOON RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-6041
Mailing Address - Country:US
Mailing Address - Phone:814-414-8923
Mailing Address - Fax:
Practice Address - Street 1:1001 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-2105
Practice Address - Country:US
Practice Address - Phone:724-223-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP453781183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist