Provider Demographics
NPI:1821357658
Name:LYSZCZARZ, ELAINE MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARIE
Last Name:LYSZCZARZ
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 1:10433 TURNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6821
Mailing Address - Country:US
Mailing Address - Phone:315-732-5642
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:NY
Practice Address - Zip Code:13492-1027
Practice Address - Country:US
Practice Address - Phone:315-768-7470
Practice Address - Fax:315-768-2383
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist