Provider Demographics
NPI:1508158676
Name:FLECK, MARY JANE (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:FLECK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946-7107
Mailing Address - Country:US
Mailing Address - Phone:814-736-9362
Mailing Address - Fax:
Practice Address - Street 1:630 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:PA
Practice Address - Zip Code:15946-7107
Practice Address - Country:US
Practice Address - Phone:814-736-4323
Practice Address - Fax:814-736-4081
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP029631L183500000X
TN0000034087183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist