Healthcare Provider Details

I. General information

NPI: 1720108756
Provider Name (Legal Business Name): EVANS CITY APOTHECARY AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 N WASHINGTON ST
EVANS CITY PA
16033-1063
US

IV. Provider business mailing address

122 N WASHINGTON ST
EVANS CITY PA
16033-1063
US

V. Phone/Fax

Practice location:
  • Phone: 724-538-3667
  • Fax: 724-538-3826
Mailing address:
  • Phone: 724-538-3667
  • Fax: 724-538-3826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPP415497L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. JEFFREY P MUSTOVIC
Title or Position: OWNER PHARMACIST
Credential:
Phone: 724-538-3667