Provider Demographics
NPI:1023309317
Name:LEWYCKYJ, PETER (RPH)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LEWYCKYJ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:PETRO
Other - Middle Name:
Other - Last Name:LEWYCKYJ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:31700 VAN DYKE AVE.
Mailing Address - Street 2:ST JOHN PHARMACY, SUITE 190
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-7952
Mailing Address - Country:US
Mailing Address - Phone:586-276-8000
Mailing Address - Fax:
Practice Address - Street 1:31700 VAN DYKE AVE.
Practice Address - Street 2:ST JOHN PHARMACY, SUITE 190
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7951
Practice Address - Country:US
Practice Address - Phone:586-276-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025719183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist