Provider Demographics
NPI:1881721090
Name:BRAKER-WOLOSZCZUK, KATHLEEN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BRAKER-WOLOSZCZUK
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 557
Mailing Address - Street 2:
Mailing Address - City:SUSQUEHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18847-9778
Mailing Address - Country:US
Mailing Address - Phone:570-756-2885
Mailing Address - Fax:
Practice Address - Street 1:601 PARK ST
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1445
Practice Address - Country:US
Practice Address - Phone:570-253-8163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP034062L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist