Healthcare Provider Details

I. General information

NPI: 1235217175
Provider Name (Legal Business Name): MRS. LISA RAE MOLLICA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 N MORGANTOWN ST
FAIRCHANCE PA
15436-1038
US

IV. Provider business mailing address

19 ALBERT ST
UNIONTOWN PA
15401-5303
US

V. Phone/Fax

Practice location:
  • Phone: 724-564-1700
  • Fax: 724-564-1704
Mailing address:
  • Phone: 724-439-9402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPP481222
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: