1235222415 NPI number — MRS. WENDY ANN DORMINEY PHARM D CDM

Table of content: MRS. WENDY ANN DORMINEY PHARM D CDM (NPI 1235222415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235222415 NPI number — MRS. WENDY ANN DORMINEY PHARM D CDM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORMINEY
Provider First Name:
WENDY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHARM D CDM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KUTER
Provider Other First Name:
WENDY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235222415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5409 FRANCIS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE PARK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-559-1318
Provider Business Mailing Address Fax Number:
229-559-9408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1016 LAKES BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-559-9398
Provider Business Practice Location Address Fax Number:
229-559-9408
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH020837 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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