1811593692 NPI number — KATHLEEN ELIZABETH WILLS-CUSH RPH

Table of content: KATHLEEN ELIZABETH WILLS-CUSH RPH (NPI 1811593692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811593692 NPI number — KATHLEEN ELIZABETH WILLS-CUSH RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLS-CUSH
Provider First Name:
KATHLEEN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811593692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
491 VALLEY ST APT 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07050-1255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-801-5029
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
865 W GRAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07202-1001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-558-0049
Provider Business Practice Location Address Fax Number:
908-558-8991
Provider Enumeration Date:
12/08/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  28RI02354500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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