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General NPI Number Information
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NPI Number | 1386865020
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Entity Type | Individual
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Provider Name | MIA WYATT
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Gender | Female
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2250 HICKORY RD SUITE 240
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City | PLYMOUTH MEETING
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State | PA
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Zip | 19462-1047
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Country | US
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Telephone | 610-834-1122
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Fax |
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Provider Business Mailing Address
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Address Line | 7762 CHATFIELD LN
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City | ELLICOTT CITY
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State | MD
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Zip | 21043-7915
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Country | US
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Telephone | 410-796-3949
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 09893
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License Number State | MD
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