MEDICARE: DR. AGNIESZKA MARIA WYDRA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	28RI03382700	NJ

General Provider Information

NPI Number	:	1407137185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AGNIESZKA MARIA WYDRA

Provider Business Mailing Address
First Line	:	207 SUNSHINE CT
Second Line	:
City	:	PARLIN
State	:	NJ
Zip	:	08859-2402
Country	:	US
Telephone Number	:	908-268-7405
Fax Number	:

Provider Business Practice Location Address
First Line	:	899 MOUNTAIN AVE
Second Line	:	FL. 3
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-3455
Country	:	US
Telephone Number	:	973-376-1701
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2011
Last Update Date	:	09/07/2011

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