Provider Demographics
NPI:1376024463
Name:SMALL, WENDY (RPH)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-3230
Mailing Address - Country:US
Mailing Address - Phone:716-844-9900
Mailing Address - Fax:
Practice Address - Street 1:188 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-3230
Practice Address - Country:US
Practice Address - Phone:716-844-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0005226183500000X
VA0202012186183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist