Healthcare Provider Details

I. General information

NPI: 1457489775
Provider Name (Legal Business Name): LARRY JAY HILDEBRAND RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 MAIN ST 47
MARENGO OH
43334
US

IV. Provider business mailing address

27 MAIN ST PO BOX 47
MARENGO OH
43334
US

V. Phone/Fax

Practice location:
  • Phone: 419-253-3831
  • Fax:
Mailing address:
  • Phone: 419-253-3831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03-1-12222
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: