Provider Demographics
NPI:1841252772
Name:WALTER CWIETNIEWICZ
Entity type:Organization
Organization Name:WALTER CWIETNIEWICZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPH/PROP
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:CWIETNIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:215-765-1903
Mailing Address - Street 1:2441 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-1931
Mailing Address - Country:US
Mailing Address - Phone:215-765-1903
Mailing Address - Fax:215-236-6606
Practice Address - Street 1:2441 BROWN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-1931
Practice Address - Country:US
Practice Address - Phone:215-765-1903
Practice Address - Fax:215-236-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP410688L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2086924OtherPK
PA1157371Medicaid
0238420001Medicare NSC