Healthcare Provider Details

I. General information

NPI: 1073225207
Provider Name (Legal Business Name): KONNOR CHARLES CHESNUTTE CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 E MANSFIELD ST
BUCYRUS OH
44820-2075
US

IV. Provider business mailing address

1875 E MANSFIELD ST
BUCYRUS OH
44820-2075
US

V. Phone/Fax

Practice location:
  • Phone: 419-562-8411
  • Fax:
Mailing address:
  • Phone: 419-562-8411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number09315404
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: