=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891395679
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN J GUSTETIC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2020
-----------------------------------------------------
Last Update Date | 10/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20245 ROUTE 19
-----------------------------------------------------
City | CRANBERRY TOWNSHIP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16066-6101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-772-4553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340 WARRICK DR
-----------------------------------------------------
City | SEVEN FIELDS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16046-8018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPI008517
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP040091L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------