Healthcare Provider Details

I. General information

NPI: 1821357658
Provider Name (Legal Business Name): ELAINE MARIE LYSZCZARZ RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAIN ST
WHITESBORO NY
13492-1027
US

IV. Provider business mailing address

10433 TURNPIKE RD
UTICA NY
13502-6821
US

V. Phone/Fax

Practice location:
  • Phone: 315-768-7470
  • Fax: 315-768-2383
Mailing address:
  • Phone: 315-732-5642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number037713
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: