Healthcare Provider Details

I. General information

NPI: 1861805129
Provider Name (Legal Business Name): LISA MINECCI KUTNEY PHARM.D., R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12311 ACADEMY RD
PHILADELPHIA PA
19154-1927
US

IV. Provider business mailing address

12311 ACADEMY RD
PHILADELPHIA PA
19154-1927
US

V. Phone/Fax

Practice location:
  • Phone: 215-637-4690
  • Fax: 215-637-6121
Mailing address:
  • Phone: 215-637-4690
  • Fax: 215-637-6121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP445354
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPI006334
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI02452800
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH8266
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: