Provider Demographics
NPI:1194016220
Name:CASTANZA, JAN DALE (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:DALE
Last Name:CASTANZA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 BACK BAY RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-9742
Mailing Address - Country:US
Mailing Address - Phone:419-823-3055
Mailing Address - Fax:419-823-3055
Practice Address - Street 1:1330 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-1011
Practice Address - Country:US
Practice Address - Phone:419-878-8384
Practice Address - Fax:419-878-5820
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-24
Last Update Date:2011-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03124476183500000X
MA15098183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist