Provider Demographics
NPI:1952183055
Name:WASIAKOWSKI, LEEANN
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:WASIAKOWSKI
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 1:39 W SIDE MALL
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3113
Mailing Address - Country:US
Mailing Address - Phone:570-287-7350
Mailing Address - Fax:570-331-0355
Practice Address - Street 1:39 W SIDE MALL
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18704-3113
Practice Address - Country:US
Practice Address - Phone:570-287-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP458045183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist