Healthcare Provider Details

I. General information

NPI: 1568666873
Provider Name (Legal Business Name): BRIAN WIENZEK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 S PERIMETER RD
LONDONDERRY NH
03053-2041
US

IV. Provider business mailing address

118 DONAHUE DR
MANCHESTER NH
03103-6107
US

V. Phone/Fax

Practice location:
  • Phone: 603-625-6406
  • Fax: 603-641-6754
Mailing address:
  • Phone: 603-644-1929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberR1198
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number033-0002984
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: