Healthcare Provider Details

I. General information

NPI: 1558724302
Provider Name (Legal Business Name): JESSE WITYCZAK PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BOLSTAD AVE E
LONG BEACH WA
98631
US

IV. Provider business mailing address

1433 12TH AVE APT. 302
SEATTLE WA
98122-3961
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-2349
  • Fax:
Mailing address:
  • Phone: 208-816-6884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPH60465766
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: