Provider Demographics
NPI:1336432574
Name:STANCZAK, JERRY P
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:P
Last Name:STANCZAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 FENIMORE BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01108-3518
Mailing Address - Country:US
Mailing Address - Phone:413-222-5788
Mailing Address - Fax:
Practice Address - Street 1:23 FENIMORE BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01108-3518
Practice Address - Country:US
Practice Address - Phone:413-222-5788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17471183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist