Provider Demographics
NPI:1619958394
Name:SELLECCHIA, ANTONIO MARIO JR
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:MARIO
Last Name:SELLECCHIA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 TORRESDALE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19135-1313
Mailing Address - Country:US
Mailing Address - Phone:215-624-0919
Mailing Address - Fax:215-624-0920
Practice Address - Street 1:7100 TORRESDALE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19135-1313
Practice Address - Country:US
Practice Address - Phone:215-624-0919
Practice Address - Fax:215-624-0920
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP045337L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5274800001Medicare ID - Type Unspecified