Provider Demographics
NPI:1669250312
Name:KECHISEN, DUSTIN MICHAEL (PHARMD)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:MICHAEL
Last Name:KECHISEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 CENTRE RD
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:16666-9104
Mailing Address - Country:US
Mailing Address - Phone:814-577-4086
Mailing Address - Fax:
Practice Address - Street 1:1101 N ATHERTON ST
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2927
Practice Address - Country:US
Practice Address - Phone:814-234-4761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-14
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP457957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist