Healthcare Provider Details

I. General information

NPI: 1497369755
Provider Name (Legal Business Name): TANYA LOUISE ISENHART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2907 STATE ST
GASSAWAY WV
26624-7849
US

IV. Provider business mailing address

2907 STATE ST
GASSAWAY WV
26624-7849
US

V. Phone/Fax

Practice location:
  • Phone: 304-364-5161
  • Fax: 304-364-8951
Mailing address:
  • Phone: 304-364-5161
  • Fax: 304-364-8951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0006079
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: