Provider Demographics
NPI:1982173993
Name:WASIAK, CAMILLE (RPH)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:WASIAK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 E OWENS APT 4
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-6027
Mailing Address - Country:US
Mailing Address - Phone:928-532-5502
Mailing Address - Fax:
Practice Address - Street 1:5160 S WHITE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7826
Practice Address - Country:US
Practice Address - Phone:928-532-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS0236151835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist