Provider Demographics
NPI:1205468121
Name:HART, CARISSA ANN
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANN
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 SHOEMAKER ST
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-2734
Mailing Address - Country:US
Mailing Address - Phone:570-241-3593
Mailing Address - Fax:
Practice Address - Street 1:921 VIEWMONT DR
Practice Address - Street 2:
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1663
Practice Address - Country:US
Practice Address - Phone:570-558-7696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP454158183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist