Provider Demographics
NPI:1407137185
Name:WYDRA, AGNIESZKA MARIA
Entity Type:Individual
Prefix:DR
First Name:AGNIESZKA
Middle Name:MARIA
Last Name:WYDRA
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 1:207 SUNSHINE CT
Mailing Address - Street 2:
Mailing Address - City:PARLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08859-2402
Mailing Address - Country:US
Mailing Address - Phone:908-268-7405
Mailing Address - Fax:
Practice Address - Street 1:899 MOUNTAIN AVE
Practice Address - Street 2:FL. 3
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-3455
Practice Address - Country:US
Practice Address - Phone:973-376-1701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03382700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist