Provider Demographics
NPI:1033304308
Name:WIENNER, STEPHEN M (BSP)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:WIENNER
Suffix:
Gender:M
Credentials:BSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CATHEDRAL ST
Mailing Address - Street 2:MT. VERNON PHARMACY
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5311
Mailing Address - Country:US
Mailing Address - Phone:410-539-8030
Mailing Address - Fax:
Practice Address - Street 1:900 CATHEDRAL ST
Practice Address - Street 2:MT. VERNON PHARMACY
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5311
Practice Address - Country:US
Practice Address - Phone:410-539-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12546183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist