Healthcare Provider Details

I. General information

NPI: 1528330123
Provider Name (Legal Business Name): RYAN JOSEPH FENNICK PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 JAMESON WAY
SEVEN FIELDS PA
16046-4324
US

IV. Provider business mailing address

142 JAMESON WAY
SEVEN FIELDS PA
16046-4324
US

V. Phone/Fax

Practice location:
  • Phone: 724-822-5359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number442320
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number11740
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberRPH.03329014-3
License Number StateOH

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: