Provider Demographics
NPI:1689033391
Name:WYSZYNSKI, IVY (RPH)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:WYSZYNSKI
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 1:1014 TASKER LN
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-3008
Mailing Address - Country:US
Mailing Address - Phone:254-289-8888
Mailing Address - Fax:
Practice Address - Street 1:200 KENT LNDG
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21666-2582
Practice Address - Country:US
Practice Address - Phone:410-643-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23919183500000X
VA0202207535183500000X
PARP042416L183500000X
TX41126183500000X
CO14828183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist