Healthcare Provider Details

I. General information

NPI: 1912306119
Provider Name (Legal Business Name): IAN KISH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 E CARSON ST
PITTSBURGH PA
15203-1835
US

IV. Provider business mailing address

133 S 18TH ST APT # 1
PITTSBURGH PA
15203-1867
US

V. Phone/Fax

Practice location:
  • Phone: 412-381-1464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP449064
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: