Provider Demographics
NPI:1376120899
Name:NIETZ, CONNIE COLLINS (RPH)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:COLLINS
Last Name:NIETZ
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 1:29240 BELMONT FARM RD
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-3783
Mailing Address - Country:US
Mailing Address - Phone:419-345-8460
Mailing Address - Fax:
Practice Address - Street 1:1330 N REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-4760
Practice Address - Country:US
Practice Address - Phone:419-536-3840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-12717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03-2-12717OtherPHARMACY LICENSE