Healthcare Provider Details

I. General information

NPI: 1912306994
Provider Name (Legal Business Name): HARTSEL PAUL FREDERICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2014
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5054 BENNINGTON DR
CROSS LANES WV
25313-2051
US

IV. Provider business mailing address

5054 BENNINGTON DR
CROSS LANES WV
25313-2051
US

V. Phone/Fax

Practice location:
  • Phone: 304-776-2789
  • Fax: 304-776-0787
Mailing address:
  • Phone: 304-776-2789
  • Fax: 304-776-0787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP0003388
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03113560
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: