Provider Demographics
NPI:1073225207
Name:CHESNUTTE, KONNOR CHARLES (CPHT)
Entity Type:Individual
Prefix:MR
First Name:KONNOR
Middle Name:CHARLES
Last Name:CHESNUTTE
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-1554
Mailing Address - Country:US
Mailing Address - Phone:419-332-2186
Mailing Address - Fax:
Practice Address - Street 1:2020 W STATE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-1554
Practice Address - Country:US
Practice Address - Phone:419-332-2186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09315404183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician