Healthcare Provider Details

I. General information

NPI: 1083161921
Provider Name (Legal Business Name): BRIAN MICHAEL CEBULKO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 W OLIVE ST
SCRANTON PA
18508-2572
US

IV. Provider business mailing address

3 W OLIVE ST
SCRANTON PA
18508-2572
US

V. Phone/Fax

Practice location:
  • Phone: 570-207-5970
  • Fax: 570-207-5971
Mailing address:
  • Phone: 570-207-5970
  • Fax: 570-207-5971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP448692
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierRP448692
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCOMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF PROFESSIONAL AND OCCU
# 2
IdentifierRPI008586
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCOMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF PROFESSIONAL AND OCCU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: