Provider Demographics
NPI:1194959783
Name:WASYNCZUK, ANNE M
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:M
Last Name:WASYNCZUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-3762
Mailing Address - Country:US
Mailing Address - Phone:765-497-8642
Mailing Address - Fax:765-497-8593
Practice Address - Street 1:3851 N RIVER RD
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-3762
Practice Address - Country:US
Practice Address - Phone:765-497-8642
Practice Address - Fax:765-497-8593
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019353A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist