Provider Demographics
NPI:1053865683
Name:WIANT, KORTNEY MARIE
Entity Type:Individual
Prefix:
First Name:KORTNEY
Middle Name:MARIE
Last Name:WIANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825-2514
Mailing Address - Country:US
Mailing Address - Phone:814-849-5217
Mailing Address - Fax:
Practice Address - Street 1:240 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-2514
Practice Address - Country:US
Practice Address - Phone:814-849-5217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP450691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist