Healthcare Provider Details

I. General information

NPI: 1609606714
Provider Name (Legal Business Name): EPHRAIM KELSEN ST CYR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/05/2024
Certification Date: 08/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 HOWLEY ST
PITTSBURGH PA
15224-1509
US

IV. Provider business mailing address

4411 HOWLEY STREET
PITTSBURGH PA
15224
US

V. Phone/Fax

Practice location:
  • Phone: 412-621-9987
  • Fax: 412-621-3041
Mailing address:
  • Phone: 412-621-9987
  • Fax: 412-621-3041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP458556
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: