Healthcare Provider Details

I. General information

NPI: 1477483329
Provider Name (Legal Business Name): AUSTIN THOMAS MONDLOCH PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10627 DIEBOLD RD
FORT WAYNE IN
46845-8606
US

IV. Provider business mailing address

10627 DIEBOLD RD
FORT WAYNE IN
46845-8606
US

V. Phone/Fax

Practice location:
  • Phone: 920-918-1110
  • Fax:
Mailing address:
  • Phone: 920-918-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number26030450A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: