Provider Demographics
NPI:1942368592
Name:CELLERARI, JACK L (RPH)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:L
Last Name:CELLERARI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SUSQUEHANNOCK DR
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-2748
Mailing Address - Country:US
Mailing Address - Phone:570-654-9919
Mailing Address - Fax:
Practice Address - Street 1:100 OLD LACKAWANNA TRL
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-9108
Practice Address - Country:US
Practice Address - Phone:570-587-4717
Practice Address - Fax:570-587-2619
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP030944L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP030944LOtherSTATE LICENSE NUMBER