Healthcare Provider Details

I. General information

NPI: 1982306965
Provider Name (Legal Business Name): MRS. TABITHA JILL WORTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. TABITHA JILL HOFFER

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 03/21/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 E MAIN ST
LEXINGTON OH
44904-1336
US

IV. Provider business mailing address

355 E MAIN ST
LEXINGTON OH
44904-1336
US

V. Phone/Fax

Practice location:
  • Phone: 419-884-6107
  • Fax: 419-884-6220
Mailing address:
  • Phone: 419-884-6107
  • Fax: 419-886-6220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number09317579
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: