Provider Demographics
NPI:1356327779
Name:REVILAK, MICHAEL D (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:REVILAK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-1656
Mailing Address - Country:US
Mailing Address - Phone:570-969-4132
Mailing Address - Fax:
Practice Address - Street 1:RR 6 BOX 6220
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:PA
Practice Address - Zip Code:18444-9062
Practice Address - Country:US
Practice Address - Phone:570-842-7848
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP043637L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist