Provider Demographics
NPI:1568561090
Name:WIECKOWSKI, LILIAN ANN
Entity Type:Individual
Prefix:
First Name:LILIAN
Middle Name:ANN
Last Name:WIECKOWSKI
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 1:11714 UNION TPKE
Mailing Address - Street 2:APT AB2
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-1045
Mailing Address - Country:US
Mailing Address - Phone:718-793-9595
Mailing Address - Fax:
Practice Address - Street 1:911 MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-2162
Practice Address - Country:US
Practice Address - Phone:718-383-7822
Practice Address - Fax:718-389-7940
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039682-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist