Healthcare Provider Details

I. General information

NPI: 1154925121
Provider Name (Legal Business Name): MONICA THERESA CICCIMARO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 DOYLESTOWN RD
LANSDALE PA
19446-1413
US

IV. Provider business mailing address

548 DOYLESTOWN RD
LANSDALE PA
19446-1413
US

V. Phone/Fax

Practice location:
  • Phone: 215-997-2852
  • Fax: 215-997-5866
Mailing address:
  • Phone: 215-997-2852
  • Fax: 215-997-5866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP040219L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: