Healthcare Provider Details

I. General information

NPI: 1023738077
Provider Name (Legal Business Name): ETHAN PENNYWITT PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 W MAIN ST
GAYLORD MI
49735-1859
US

IV. Provider business mailing address

800 SILVER PINE CIR APT 30
GAYLORD MI
49735-9804
US

V. Phone/Fax

Practice location:
  • Phone: 989-732-5220
  • Fax:
Mailing address:
  • Phone: 419-973-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302414620
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: