MEDICARE: MR. LLEWELLYN PETER HARTOGH RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RPH56714	CA
2	183500000X	Pharmacist	69376	TX

General Provider Information

NPI Number	:	1326365255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LLEWELLYN PETER HARTOGH RPH

Provider Business Mailing Address
First Line	:	9940 SIERRA AVE
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92335-6721
Country	:	US
Telephone Number	:	909-822-8122
Fax Number	:	909-822-5855

Provider Business Practice Location Address
First Line	:	2603 W BERRY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-1770
Country	:	US
Telephone Number	:	817-923-8259
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2010
Last Update Date	:	10/14/2021

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