Provider Demographics
NPI:1790074391
Name:SPEAL-PAVOLIK, CARRIE ANN (RPH)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:SPEAL-PAVOLIK
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 1:621 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3123
Mailing Address - Country:US
Mailing Address - Phone:724-541-2312
Mailing Address - Fax:
Practice Address - Street 1:375 PHILADELPHIA ST
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-2068
Practice Address - Country:US
Practice Address - Phone:724-465-2243
Practice Address - Fax:724-465-0307
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP037685L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP037685LOtherPENNSYLVANIA STATE BOARD OF PHARMACY