Healthcare Provider Details

I. General information

NPI: 1871938233
Provider Name (Legal Business Name): CRAIG S KONZEN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 CHARLESTON RD
WELLSBORO PA
16901-8351
US

IV. Provider business mailing address

545 CHARLESTON ROAD
WELLSBORO PA
16901
US

V. Phone/Fax

Practice location:
  • Phone: 570-723-1079
  • Fax:
Mailing address:
  • Phone: 570-723-1079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License NumberRP440470
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: