Healthcare Provider Details

I. General information

NPI: 1811002355
Provider Name (Legal Business Name): DONALD H. WENTZEL R PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 DRY LANE RD N
LA RUE OH
43332-9510
US

IV. Provider business mailing address

2005 DRY LANE RD N
LA RUE OH
43332-9510
US

V. Phone/Fax

Practice location:
  • Phone: 740-499-3654
  • Fax: 740-499-3654
Mailing address:
  • Phone: 740-499-3654
  • Fax: 740-499-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03-3-08714
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11031
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26017852
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13366
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: