Healthcare Provider Details

I. General information

NPI: 1417170507
Provider Name (Legal Business Name): STANISLAVA KILIMNIK REG PHARM TECH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 COTTMAN AVE
PHILADELPHIA PA
19149-1230
US

IV. Provider business mailing address

500 S BROAD ST
PHILADELPHIA PA
19146-1613
US

V. Phone/Fax

Practice location:
  • Phone: 215-685-0616
  • Fax:
Mailing address:
  • Phone: 215-685-6864
  • Fax: 215-790-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number290101040762276
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: