Provider Demographics
NPI:1558724302
Name:WITYCZAK, JESSE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:WITYCZAK
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 1:1433 12TH AVE
Mailing Address - Street 2:APT. 302
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-3961
Mailing Address - Country:US
Mailing Address - Phone:208-816-6884
Mailing Address - Fax:
Practice Address - Street 1:101 BOLSTAD AVE E
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631
Practice Address - Country:US
Practice Address - Phone:360-642-2349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH604657661835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care