=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134720253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JON ADAM WOEBKENBERG PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2020
-----------------------------------------------------
Last Update Date | 11/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 W BROADWAY ST
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47670-9418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-386-6690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10710 DECATUR CT
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47725-9289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-568-5819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26020449A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------