Provider Demographics
NPI:1376033639
Name:HARTER, BRENDA LEE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:HARTER
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 1:2200 RANDALLIA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4699
Mailing Address - Country:US
Mailing Address - Phone:260-373-3469
Mailing Address - Fax:260-373-3418
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-3469
Practice Address - Fax:260-373-3418
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-12
Last Update Date:2018-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03317216183500000X
IN26016240A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist