Healthcare Provider Details

I. General information

NPI: 1780242552
Provider Name (Legal Business Name): MARK WYSOCKI PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 PARK ST
NEW HAVEN CT
06511-5474
US

IV. Provider business mailing address

55 PARK ST
NEW HAVEN CT
06511-5474
US

V. Phone/Fax

Practice location:
  • Phone: 203-200-4444
  • Fax:
Mailing address:
  • Phone: 203-200-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License NumberPCT.0014169
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: