Healthcare Provider Details

I. General information

NPI: 1447615620
Provider Name (Legal Business Name): LARRY CICERO RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 PLANK RD
DUNCANSVILLE PA
16635-8456
US

IV. Provider business mailing address

1333 PLANK RD
DUNCANSVILLE PA
16635-8456
US

V. Phone/Fax

Practice location:
  • Phone: 855-265-8008
  • Fax: 814-283-2211
Mailing address:
  • Phone: 855-265-8008
  • Fax: 814-283-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRP029969L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: