Provider Demographics
NPI:1275271207
Name:FASNACHT, RANDY (RPH)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:FASNACHT
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 1:21 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:DENNISON
Mailing Address - State:OH
Mailing Address - Zip Code:44621-1270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 GRANT ST
Practice Address - Street 2:
Practice Address - City:DENNISON
Practice Address - State:OH
Practice Address - Zip Code:44621-1270
Practice Address - Country:US
Practice Address - Phone:740-922-2591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03215153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist