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General NPI Number Information
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NPI Number | 1720080757
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Entity Type | Individual
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Provider Name | MARK STEPHEN DOMINIK R.PH.
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Gender | Male
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Dates
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Enumeration Date | 08/10/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2 N WASHINGTON ST
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City | NEW BREMEN
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State | OH
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Zip | 45869-1113
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Country | US
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Telephone | 419-629-2336
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Fax |
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Provider Business Mailing Address
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Address Line | 1806 FENWAY CT
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City | ST MARYS
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State | OH
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Zip | 45885-1365
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Country | US
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Telephone | 419-394-7259
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 03-11-4978
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License Number State | OH
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